MEDICARE: DEIDRA WHITE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN 117058 NP	GA
2	363L00000X	Nurse Practitioner	117058	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568595775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRA WHITE NP

Provider Business Mailing Address
First Line	:	148 BILL CARRUTH PKWY STE 220
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-3756
Country	:	US
Telephone Number	:	775-505-0023
Fax Number	:

Provider Business Practice Location Address
First Line	:	148 BILL CARRUTH PKWY STE 220
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-3756
Country	:	US
Telephone Number	:	770-505-0023
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	10/10/2025

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Directions to “ DEIDRA WHITE NP” Practice Location

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