Provider Demographics
NPI:1386114510
Name:SIMMERMAN, TABITHA JO
Entity type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:JO
Last Name:SIMMERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 VANDY AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-7184
Mailing Address - Country:US
Mailing Address - Phone:901-606-6331
Mailing Address - Fax:
Practice Address - Street 1:4700 MUELLER BRASS RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3754
Practice Address - Country:US
Practice Address - Phone:901-476-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN000077163164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse