MEDICARE: KRISTA L TABLER GRESHAM NP

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	363LF0000X	Family Nurse Practitioner	AP127019	TX

General Provider Information

NPI Number	:	1700243730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA L TABLER GRESHAM NP

Provider Business Mailing Address
First Line	:	525 N BRENTWOOD
Second Line	:
City	:	LUFKIN
State	:	TX
Zip	:	75904-7124
Country	:	US
Telephone Number	:	936-205-2778
Fax Number	:	936-873-8753

Provider Business Practice Location Address
First Line	:	525 N BRENTWOOD
Second Line	:
City	:	LUFKIN
State	:	TX
Zip	:	75904-7124
Country	:	US
Telephone Number	:	936-205-2778
Fax Number	:	936-873-8753

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

Provider Enumeration Date	:	01/21/2016
Last Update Date	:	03/17/2026

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