MEDICARE: TABITHA INDRIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	790440	CA
2	363LP2300X	Primary Care Nurse Practitioner	95006380	CA

General Provider Information

NPI Number	:	1639602766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITHA INDRIES

Provider Business Mailing Address
First Line	:	25671 PADUA DR
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-5119
Country	:	US
Telephone Number	:	949-903-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	25671 PADUA DR
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-5119
Country	:	US
Telephone Number	:	949-903-2700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2017
Last Update Date	:	04/05/2017

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