Healthcare Provider Details

I. General information

NPI: 1699097592
Provider Name (Legal Business Name): SANDRA GAIL TABER A.P.R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 N 30TH ST
PADUCAH KY
42001-4047
US

IV. Provider business mailing address

619 N 30TH ST
PADUCAH KY
42001-4047
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-8183
  • Fax: 270-444-8147
Mailing address:
  • Phone: 270-444-8183
  • Fax: 270-444-8147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3006232
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number3006232
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1040966
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: