Provider Demographics
NPI:1255584637
Name:WHITE, OTTYSHA A (APRN)
Entity type:Individual
Prefix:
First Name:OTTYSHA
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:OTTYSHA
Other - Middle Name:
Other - Last Name:HADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-301-2092
Practice Address - Street 1:416 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3108
Practice Address - Country:US
Practice Address - Phone:870-333-5476
Practice Address - Fax:870-333-5475
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004401363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR208360758Medicaid
AR414469YJG2Medicare PIN