Healthcare Provider Details

I. General information

NPI: 1588006928
Provider Name (Legal Business Name): TABETHA MARIE GEHRKE AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2013
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 SAINT FRANCIS DR STE 320
WATERLOO IA
50702-5620
US

IV. Provider business mailing address

719 WISCONSIN ST
WATERLOO IA
50702-1822
US

V. Phone/Fax

Practice location:
  • Phone: 319-272-5000
  • Fax:
Mailing address:
  • Phone: 319-239-7393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberL104204
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: