Provider Demographics
NPI:1265008395
Name:TABTAB, MA CAMILLE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MA CAMILLE
Middle Name:
Last Name:TABTAB
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75653-0774
Mailing Address - Country:US
Mailing Address - Phone:903-392-9886
Mailing Address - Fax:
Practice Address - Street 1:108 S MAIN ST UNIT 555
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785-1335
Practice Address - Country:US
Practice Address - Phone:903-392-9886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-30
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1041920363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health