Healthcare Provider Details

I. General information

NPI: 1588582654
Provider Name (Legal Business Name): TABITHA RENEE LAWLESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 STEVE DR
RUSSELL SPRINGS KY
42642-4622
US

IV. Provider business mailing address

11 ZIMMERMAN RD
JAMESTOWN KY
42629-2139
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-3161
  • Fax:
Mailing address:
  • Phone: 270-866-3161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4060400
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: