Provider Demographics
NPI:1699130500
Name:WANJIKU, TABITHA (NP)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:WANJIKU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 GRANDVIEW LN
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-8706
Mailing Address - Country:US
Mailing Address - Phone:404-917-7405
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR STE 103
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3255
Practice Address - Country:US
Practice Address - Phone:770-838-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177708363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner