Healthcare Provider Details

I. General information

NPI: 1689831562
Provider Name (Legal Business Name): CARMEN PHILLIPS WHITE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 MAIN ST STE C
LAKE DALLAS TX
75065-2878
US

IV. Provider business mailing address

503 MAIN ST STE C
LAKE DALLAS TX
75065-2878
US

V. Phone/Fax

Practice location:
  • Phone: 940-535-5296
  • Fax: 972-535-5297
Mailing address:
  • Phone: 940-535-5296
  • Fax: 972-535-5297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number687867
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP116632
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: