Provider Demographics
NPI:1205104353
Name:TOLBERT, PRISCILLA ANTONETTE
Entity type:Individual
Prefix:MISS
First Name:PRISCILLA
Middle Name:ANTONETTE
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:PRISCILLA
Other - Middle Name:ANTONETTE
Other - Last Name:MAHADEVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:4430 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-9098
Mailing Address - Country:US
Mailing Address - Phone:573-596-9843
Mailing Address - Fax:573-596-5334
Practice Address - Street 1:4430 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-9843
Practice Address - Fax:573-596-5334
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6482098-4405363LG0600X
OH2017025995363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology