Provider Demographics
NPI:1730711979
Name:WHITE, KRISTEN DAWN
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DAWN
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 1:5714 LOS ROBLES CT
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-2215
Mailing Address - Country:US
Mailing Address - Phone:941-705-5699
Mailing Address - Fax:
Practice Address - Street 1:5714 LOS ROBLES CT
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-2215
Practice Address - Country:US
Practice Address - Phone:941-705-5699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL222Q00000XMedicaid