Provider Demographics
NPI:1073003117
Name:SMITH, TABITHA LYNN (APRN)
Entity Type:Individual
Prefix:MS
First Name:TABITHA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37925 ROCKSPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:OH
Mailing Address - Zip Code:45769-9317
Mailing Address - Country:US
Mailing Address - Phone:740-416-0797
Mailing Address - Fax:
Practice Address - Street 1:4114 1ST AVE
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1304
Practice Address - Country:US
Practice Address - Phone:304-755-0119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN64058-NP-C363LP0808X, 363LF0000X
OHAPRN.CNP.024594363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0378928Medicaid
WV1174021406Medicaid