Provider Demographics
NPI:1962584375
Name:SIMPSON, TABITHA DEE
Entity type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:DEE
Last Name:SIMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TABITHA
Other - Middle Name:DEE
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-0230
Mailing Address - Country:US
Mailing Address - Phone:812-268-3318
Mailing Address - Fax:
Practice Address - Street 1:2200 N SECTION ST STE A
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7523
Practice Address - Country:US
Practice Address - Phone:812-268-4311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001735B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200317180AOtherMEDICAID GROUP
IN200880570Medicaid
200889400OtherMEDICAID RURAL HEALTH-GROUP
IN153886Medicare Oscar/Certification
IN200317180AOtherMEDICAID GROUP