Provider Demographics
NPI:1124762695
Name:CLARK, TABITHA RYNN (CNP)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:RYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:RYNN
Other - Last Name:JEFFRIES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:110 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:519 G ROAD
Practice Address - Street 2:
Practice Address - City:ARTHURDALE
Practice Address - State:WV
Practice Address - Zip Code:26520
Practice Address - Country:US
Practice Address - Phone:304-864-0884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV112519363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care