Provider Demographics
NPI:1063075752
Name:TABOR, BRANDI NICHOLE (APRN)
Entity type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:NICHOLE
Last Name:TABOR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:BRANDI
Other - Middle Name:NICHOLE
Other - Last Name:SKAGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:733 W MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1143
Mailing Address - Country:US
Mailing Address - Phone:573-783-8875
Mailing Address - Fax:
Practice Address - Street 1:735 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1113
Practice Address - Country:US
Practice Address - Phone:573-783-8875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019011374363L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner