Healthcare Provider Details

I. General information

NPI: 1720629561
Provider Name (Legal Business Name): TABITHA CHU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 TEACO RD
KENNETT MO
63857-3266
US

IV. Provider business mailing address

304 TEACO RD
KENNETT MO
63857-3266
US

V. Phone/Fax

Practice location:
  • Phone: 573-559-3591
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number124196
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2019010243
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0042037
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: