Provider Demographics
NPI:1871291377
Name:WHITE, PERNELL
Entity type:Individual
Prefix:
First Name:PERNELL
Middle Name:
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 1:31 KELLEY RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-5607
Mailing Address - Country:US
Mailing Address - Phone:540-846-3716
Mailing Address - Fax:
Practice Address - Street 1:11447 WEDMAN CT LOT 49
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-2342
Practice Address - Country:US
Practice Address - Phone:540-846-3716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider