Provider Demographics
NPI:1548861073
Name:WHITE, KELLY MARIE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
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 1:4498 KING ARTHUR DR
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-9646
Mailing Address - Country:US
Mailing Address - Phone:330-714-8394
Mailing Address - Fax:
Practice Address - Street 1:4498 KING ARTHUR DR
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-9646
Practice Address - Country:US
Practice Address - Phone:330-714-8394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHHQA8372347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle