Provider Demographics
NPI:1710718630
Name:FAUST, TABITHA MIRANDA (CPM)
Entity type:Individual
Prefix:MS
First Name:TABITHA
Middle Name:MIRANDA
Last Name:FAUST
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 COUNTY ROAD 917
Mailing Address - Street 2:
Mailing Address - City:THEODOSIA
Mailing Address - State:MO
Mailing Address - Zip Code:65761-6155
Mailing Address - Country:US
Mailing Address - Phone:417-255-6883
Mailing Address - Fax:
Practice Address - Street 1:459 COUNTY ROAD 917
Practice Address - Street 2:
Practice Address - City:THEODOSIA
Practice Address - State:MO
Practice Address - Zip Code:65761-6155
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCPM24080529176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife