MEDICARE: KATHERYN DEE WHITE NP-C

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	28146681A	IN
2	363LF0000X	Family Nurse Practitioner	71009899A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1538717483	OTHER	IN	GROUP NPI

General Provider Information

NPI Number	:	1770117673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERYN DEE WHITE NP-C

Provider Business Mailing Address
First Line	:	PO BOX 781076
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-1076
Country	:	US
Telephone Number	:	317-528-4800
Fax Number	:	317-865-1479

Provider Business Practice Location Address
First Line	:	4500 W 181ST AVE
Second Line	:
City	:	LOWELL
State	:	IN
Zip	:	46356-0017
Country	:	US
Telephone Number	:	219-690-2016
Fax Number	:	219-690-1862

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

Provider Enumeration Date	:	02/28/2020
Last Update Date	:	07/13/2023

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