Healthcare Provider Details

I. General information

NPI: 1457722142
Provider Name (Legal Business Name): TABITHA DAWN PENA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. TABITHA DAWN HARRIS

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SAINT LOUIS AVE
SEYMOUR IN
47274-2304
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 812-524-8388
  • Fax: 812-954-5021
Mailing address:
  • Phone: 317-576-1335
  • Fax: 844-397-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28180971A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: