Provider Demographics
NPI:1992544894
Name:PENNY, TABITHA RENEE (BSN, RN)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:RENEE
Last Name:PENNY
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 COPPER OAKS ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-5891
Mailing Address - Country:US
Mailing Address - Phone:269-245-5466
Mailing Address - Fax:
Practice Address - Street 1:212 WINSTON DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-8526
Practice Address - Country:US
Practice Address - Phone:269-781-9867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704248744163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care