Healthcare Provider Details

I. General information

NPI: 1023833555
Provider Name (Legal Business Name): TABITHA JO SHEPHERD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIRCLIFF WAY
JACKSONVILLE FL
32204-4748
US

IV. Provider business mailing address

2664 COLD STREAM LN
GREEN COVE SPRINGS FL
32043-8623
US

V. Phone/Fax

Practice location:
  • Phone: 904-308-7300
  • Fax:
Mailing address:
  • Phone: 405-413-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN9580294
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number155023
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11036894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: