=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164392155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TABITHA ANN STANLEY CHW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2025
-----------------------------------------------------
Last Update Date | 11/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1107 S PEARCE ST
-----------------------------------------------------
City | OWOSSO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48867-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-832-2689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1107 S PEARCE ST
-----------------------------------------------------
City | OWOSSO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48867-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-832-2689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------