MEDICARE: MA CAMILLE TABTAB PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1041920	TX

General Provider Information

NPI Number	:	1265008395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MA CAMILLE TABTAB PMHNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 774
Second Line	:
City	:	HENDERSON
State	:	TX
Zip	:	75653-0774
Country	:	US
Telephone Number	:	903-392-9886
Fax Number	:	903-765-7573

Provider Business Practice Location Address
First Line	:	108 S MAIN ST UNIT 555
Second Line	:
City	:	RUSK
State	:	TX
Zip	:	75785-1335
Country	:	US
Telephone Number	:	903-392-9886
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2021
Last Update Date	:	12/15/2025

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