Provider Demographics
NPI:1538544960
Name:WHITE, TANGE MARIE (COTA)
Entity type:Individual
Prefix:
First Name:TANGE
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 KERNAN FOREST BLVD
Mailing Address - Street 2:2302
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5597
Mailing Address - Country:US
Mailing Address - Phone:904-894-8646
Mailing Address - Fax:
Practice Address - Street 1:925 S SEMRN BLVD
Practice Address - Street 2:110A
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-5313
Practice Address - Country:US
Practice Address - Phone:888-830-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13422171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor