Provider Demographics
NPI:1023529914
Name:HATHAWAY, TINA L
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:HATHAWAY
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 1:114 HILL POND LN
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0872
Mailing Address - Country:US
Mailing Address - Phone:912-681-6944
Mailing Address - Fax:912-681-8744
Practice Address - Street 1:114 HILL POND LN
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0872
Practice Address - Country:US
Practice Address - Phone:912-681-6944
Practice Address - Fax:912-681-8744
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165131363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN165131OtherNURSING LICENSE
GARN165131OtherNURSE PRACTITIONER