Healthcare Provider Details

I. General information

NPI: 1467401695
Provider Name (Legal Business Name): TABITHA R JUSTICE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W ELK AVE
ELIZABETHTON TN
37643-3776
US

IV. Provider business mailing address

401 E MAIN ST
JOHNSON CITY TN
37601-4877
US

V. Phone/Fax

Practice location:
  • Phone: 423-543-2584
  • Fax: 423-543-2789
Mailing address:
  • Phone: 423-929-2584
  • Fax: 423-722-2048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN11945
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number11945
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: