Provider Demographics
NPI:1407675606
Name:TABOR, BROOKE NICOLE (PMHNP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:TABOR
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 MULBERRY RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:MO
Mailing Address - Zip Code:65632-8504
Mailing Address - Country:US
Mailing Address - Phone:417-230-3648
Mailing Address - Fax:
Practice Address - Street 1:494 MULBERRY RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:MO
Practice Address - Zip Code:65632-8504
Practice Address - Country:US
Practice Address - Phone:417-230-3648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024039870363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health