Provider Demographics
NPI:1811546013
Name:KICKLIGHTER, TABITHA (PA-C)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:KICKLIGHTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 STANDARD LN
Mailing Address - Street 2:
Mailing Address - City:GLENNVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30427-7051
Mailing Address - Country:US
Mailing Address - Phone:912-237-4415
Mailing Address - Fax:
Practice Address - Street 1:2221 SW 19TH AVENUE RD UNIT 100
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-7758
Practice Address - Country:US
Practice Address - Phone:352-629-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant