Provider Demographics
NPI:1639602766
Name:INDRIES, TABITHA
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:INDRIES
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 1:25671 PADUA DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5119
Mailing Address - Country:US
Mailing Address - Phone:949-903-2700
Mailing Address - Fax:
Practice Address - Street 1:25671 PADUA DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5119
Practice Address - Country:US
Practice Address - Phone:949-903-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA790440163W00000X
CA95006380363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse