Healthcare Provider Details

I. General information

NPI: 1902282270
Provider Name (Legal Business Name): MARY TABATHA SIMON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 ENTERPRISE DR
EASLEY SC
29642-8280
US

IV. Provider business mailing address

3 PROFESSIONAL PARK DR STE 21
JOHNSON CITY TN
37604-6529
US

V. Phone/Fax

Practice location:
  • Phone: 864-365-0290
  • Fax:
Mailing address:
  • Phone: 423-434-6300
  • Fax: 423-434-6312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24643
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19600
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: