Provider Demographics
NPI:1700532967
Name:DAVIS, TABITHA JEANNE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:JEANNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-774-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017451363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner