Provider Demographics
NPI:1619372364
Name:TABISH, MADONNA
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:
Last Name:TABISH
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 1:124 HERITAGE ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59870-2746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 HERITAGE ST UNIT B
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870-2746
Practice Address - Country:US
Practice Address - Phone:406-274-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN-45341163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse