Provider Demographics
NPI:1710523436
Name:MCGOVERN, TABITHA
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:MCGOVERN
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 1:16275 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BAYVIEW
Mailing Address - State:ID
Mailing Address - Zip Code:83803-9792
Mailing Address - Country:US
Mailing Address - Phone:208-651-5950
Mailing Address - Fax:
Practice Address - Street 1:16275 E 1ST ST
Practice Address - Street 2:
Practice Address - City:BAYVIEW
Practice Address - State:ID
Practice Address - Zip Code:83803-9792
Practice Address - Country:US
Practice Address - Phone:208-651-5950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker