Provider Demographics
NPI:1568574564
Name:MARIS, TABITHA NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:NICOLE
Last Name:MARIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3748
Mailing Address - Country:US
Mailing Address - Phone:307-633-7929
Mailing Address - Fax:
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-633-7929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY26442363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily