Healthcare Provider Details

I. General information

NPI: 1932811551
Provider Name (Legal Business Name): TABITHA DENNARD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E KING ST
SEAFORD DE
19973-3505
US

IV. Provider business mailing address

8732 SHADOW LN
DELMAR MD
21875-2517
US

V. Phone/Fax

Practice location:
  • Phone: 302-628-3000
  • Fax:
Mailing address:
  • Phone: 410-251-1343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR197155
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberLP-0010626
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR197155
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: