Provider Demographics
NPI:1902952906
Name:WHITE, KELLEY J (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:J
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 BOULDER POINT DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-3170
Mailing Address - Country:US
Mailing Address - Phone:603-536-4000
Mailing Address - Fax:603-536-4001
Practice Address - Street 1:101 BOULDER POINT DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3170
Practice Address - Country:US
Practice Address - Phone:603-536-4000
Practice Address - Fax:603-536-4001
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD-026612-E208000000X
NH14003208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30208231Medicaid
PA0009170610001Medicaid
NH30208231Medicaid
PAC32452Medicare UPIN
C32452Medicare UPIN