Provider Demographics
NPI:1164392155
Name:STANLEY, TABITHA ANN (CHW)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:ANN
Last Name:STANLEY
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 S PEARCE ST
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-4343
Mailing Address - Country:US
Mailing Address - Phone:248-832-2689
Mailing Address - Fax:
Practice Address - Street 1:1107 S PEARCE ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-4343
Practice Address - Country:US
Practice Address - Phone:248-832-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-06
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty