Provider Demographics
NPI:1467401695
Name:JUSTICE, TABITHA R (APN)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:R
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4877
Mailing Address - Country:US
Mailing Address - Phone:423-929-2584
Mailing Address - Fax:423-722-2048
Practice Address - Street 1:1900 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-3776
Practice Address - Country:US
Practice Address - Phone:423-543-2584
Practice Address - Fax:423-543-2789
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11945363L00000X
TN11945207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNAPN11945OtherAPN LICENSE
TNMJ1404540OtherDEA
TN103I502819Medicare PIN
TNMJ1404540OtherDEA
TN103I508624Medicare PIN