Provider Demographics
NPI:1275122897
Name:HORN, TABITHA M
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:M
Last Name:HORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:M
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1125 HICKMAN AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-2878
Mailing Address - Country:US
Mailing Address - Phone:270-993-3102
Mailing Address - Fax:
Practice Address - Street 1:3604 WATHENS XING
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-7035
Practice Address - Country:US
Practice Address - Phone:270-684-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1139295163WG0000X
KY3015937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice