MEDICARE: TABATHA D LANDRUM 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	71009930A	IN
2	163W00000X	Registered Nurse	28186169A	IN
3	363L00000X	Nurse Practitioner	71009930A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1700398666	OTHER	IN	ANTHEM PTAN
2	1102471365	OTHER	IN	ANTHEM PTAN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700398666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABATHA D LANDRUM NP

Provider Business Mailing Address
First Line	:	PO BOX 781076
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-1008
Country	:	US
Telephone Number	:	317-528-4800
Fax Number	:	317-865-1479

Provider Business Practice Location Address
First Line	:	1205 HADLEY RD STE 120
Second Line	:
City	:	MOORESVILLE
State	:	IN
Zip	:	46158-1934
Country	:	US
Telephone Number	:	317-528-2555
Fax Number	:	317-528-2566

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

Provider Enumeration Date	:	11/01/2017
Last Update Date	:	01/06/2026

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Directions to “ TABATHA D LANDRUM NP” Practice Location

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