MEDICARE: TABITHA R JUSTICE APN

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	363L00000X	Nurse Practitioner	APN11945	TN
2	207P00000X	Emergency Medicine Physician	11945	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	APN11945	OTHER	TN	APN LICENSE

General Provider Information

NPI Number	:	1467401695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITHA R JUSTICE APN

Provider Business Mailing Address
First Line	:	401 E MAIN ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-4877
Country	:	US
Telephone Number	:	423-929-2584
Fax Number	:	423-722-2048

Provider Business Practice Location Address
First Line	:	1900 W ELK AVE
Second Line	:
City	:	ELIZABETHTON
State	:	TN
Zip	:	37643-3776
Country	:	US
Telephone Number	:	423-543-2584
Fax Number	:	423-543-2789

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

Provider Enumeration Date	:	05/06/2006
Last Update Date	:	03/07/2023

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