Healthcare Provider Details

I. General information

NPI: 1376298620
Provider Name (Legal Business Name): MICHELE WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 WATERSIDE LN
CROSS JUNCTION VA
22625-2468
US

IV. Provider business mailing address

138 WATERSIDE LN
CROSS JUNCTION VA
22625-2468
US

V. Phone/Fax

Practice location:
  • Phone: 707-628-8224
  • Fax:
Mailing address:
  • Phone: 707-628-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604268
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: