Provider Demographics
NPI:1346494028
Name:HEARN, TABITHA
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:HEARN
Suffix:
Gender:F
Credentials:
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 162
Mailing Address - Street 2:
Mailing Address - City:WEST PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12493-0162
Mailing Address - Country:US
Mailing Address - Phone:845-337-0556
Mailing Address - Fax:
Practice Address - Street 1:192 CAESARS LN
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-7743
Practice Address - Country:US
Practice Address - Phone:845-565-7463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284262-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse