Provider Demographics
NPI:1891044160
Name:KEPHART, TABITHA ANNE (CSA)
Entity Type:Individual
Prefix:MS
First Name:TABITHA
Middle Name:ANNE
Last Name:KEPHART
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2124
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-6124
Mailing Address - Country:US
Mailing Address - Phone:828-557-3580
Mailing Address - Fax:
Practice Address - Street 1:4485 HUBERT MARTIN RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30028-3269
Practice Address - Country:US
Practice Address - Phone:828-557-3580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-02
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4039246ZS0410X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist