Provider Demographics
NPI:1700398666
Name:LANDRUM, TABATHA D (FNP-C)
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:D
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:TABATHA
Other - Middle Name:
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:10568 W LINGLE LN
Mailing Address - Street 2:
Mailing Address - City:GOSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47433-8979
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 S 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4214
Practice Address - Country:US
Practice Address - Phone:812-238-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28186169A163W00000X
IN71009930A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse