Provider Demographics
NPI:1083250864
Name:BOSIRE, TABITHA NYABOKE (CNP)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:NYABOKE
Last Name:BOSIRE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:NYABOKE
Other - Last Name:OPANDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:2150 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-1287
Mailing Address - Country:US
Mailing Address - Phone:507-831-2400
Mailing Address - Fax:507-847-1119
Practice Address - Street 1:2150 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1287
Practice Address - Country:US
Practice Address - Phone:507-831-2400
Practice Address - Fax:507-847-1119
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5379573-072363LF0000X
MO2020019972363LF0000X
MN11296363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily