Healthcare Provider Details

I. General information

NPI: 1104402338
Provider Name (Legal Business Name): TABATHA GRACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S WHITE MOUNTAIN RD BLDG 3
SHOW LOW AZ
85901-7111
US

IV. Provider business mailing address

1300 S MAIN ST
SNOWFLAKE AZ
85937-5661
US

V. Phone/Fax

Practice location:
  • Phone: 928-532-5838
  • Fax:
Mailing address:
  • Phone: 928-536-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number254322
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: