Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RA0401X | Internist - Addiction Medicine | 2008-00186 | NC |
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 2008-00186 | NC |
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 90862 | GA |
NPI | 1588863161 |
---|---|
Provider Name | Mayisha White-Dunham |
First Address | Clemmons, NC 27012-8883 |
Second Address | Clemmons, NC 27012-8883 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2007 |
Last Update Date | 28/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5910806 | (05) | NC |
P00810246 | MAYISHA DUNHAM PTAN (01) |