Provider Demographics
NPI:1477580819
Name:SNOWDY, TABITHA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:
Last Name:SNOWDY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:601-200-4970
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:971 LAKELAND DR STE 954
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4609
Practice Address - Country:US
Practice Address - Phone:601-200-4714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858634207RI0200X
MS858634363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125175Medicaid
MS500001652Medicare ID - Type Unspecified
MS302I508632Medicare PIN
MS00125175Medicaid
MS512I500045Medicare PIN