Healthcare Provider Details

I. General information

NPI: 1851066401
Provider Name (Legal Business Name): KEVIN WILLSON WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2021
Last Update Date: 08/14/2021
Certification Date: 08/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 NE MERMAN DR
PULLMAN WA
99163-5069
US

IV. Provider business mailing address

1440 NE MERMAN DR
PULLMAN WA
99163-5069
US

V. Phone/Fax

Practice location:
  • Phone: 406-812-0551
  • Fax:
Mailing address:
  • Phone: 406-812-0551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number367496
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: