Provider Demographics
NPI:1871733154
Name:WHITE, GINA D (FNP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:D
Last Name:WHITE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:GINA
Other - Middle Name:D
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-582-7137
Practice Address - Fax:310-582-7140
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010027593363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360443Medicare PIN