Provider Demographics
NPI:1922262146
Name:NENNINGER, TABITHA (MD)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:NENNINGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 S 96TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3736
Mailing Address - Country:US
Mailing Address - Phone:402-936-1109
Mailing Address - Fax:
Practice Address - Street 1:1115 SE 164TH AVE DEPT 358
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-8004
Practice Address - Country:US
Practice Address - Phone:402-936-1109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE26659207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731727Medicaid
IA1922262146Medicaid
NE47068731785Medicaid
NE47068731749Medicaid
NE099099164Medicare PIN
NE47068731734Medicaid
NE47068731741Medicaid