Healthcare Provider Details

I. General information

NPI: 1568029486
Provider Name (Legal Business Name): KAELEE WHITE PTA, CSRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2019
Last Update Date: 05/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 HORIZON BLVD NE
ALBUQUERQUE NM
87113-1689
US

IV. Provider business mailing address

8820 HORIZON BLVD NE
ALBUQUERQUE NM
87113-1689
US

V. Phone/Fax

Practice location:
  • Phone: 575-998-1551
  • Fax:
Mailing address:
  • Phone: 505-998-1551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPTA1184
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: