Healthcare Provider Details

I. General information

NPI: 1518523695
Provider Name (Legal Business Name): TABITHA DAWN HOFER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TABITHA HENDRICKSON

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 PORTLAND WAY S
GALION OH
44833-2362
US

IV. Provider business mailing address

700 N COLUMBUS ST
CRESTLINE OH
44827-1455
US

V. Phone/Fax

Practice location:
  • Phone: 419-462-4656
  • Fax:
Mailing address:
  • Phone: 419-462-3485
  • Fax: 419-462-4582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP.024660
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: