Provider Demographics
NPI:1659031193
Name:HOADLEY, TABETHA
Entity Type:Individual
Prefix:
First Name:TABETHA
Middle Name:
Last Name:HOADLEY
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 1:2621 STOLL CT
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5054
Mailing Address - Country:US
Mailing Address - Phone:208-899-7119
Mailing Address - Fax:
Practice Address - Street 1:2621 STOLL CT
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5054
Practice Address - Country:US
Practice Address - Phone:208-899-7119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-25
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTEMP54497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily