Provider Demographics
NPI:1437975604
Name:WHITE, ELISA RENEE
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:RENEE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3017
Mailing Address - Country:US
Mailing Address - Phone:360-261-6930
Mailing Address - Fax:
Practice Address - Street 1:1116 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3017
Practice Address - Country:US
Practice Address - Phone:360-261-6930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1942840160175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist