Provider Demographics
NPI:1376134700
Name:RUNNER, TABBATHA ANN (RN)
Entity Type:Individual
Prefix:
First Name:TABBATHA
Middle Name:ANN
Last Name:RUNNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TABBATHA
Other - Middle Name:ANN
Other - Last Name:PEMBERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:32725 HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:LAQUEY
Mailing Address - State:MO
Mailing Address - Zip Code:65534-7672
Mailing Address - Country:US
Mailing Address - Phone:573-855-5912
Mailing Address - Fax:573-596-9588
Practice Address - Street 1:4430 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-2560
Practice Address - Fax:573-596-9588
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012007205163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management