Basic Information
| Provider Information | |||||||||
| NPI: | 1003089129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | TABITHA | ||||||||
| MiddleName: | STARR | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 W RAVINE RD | ||||||||
| Address2: | STE 3-A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232466777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | 4C | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235781595 | ||||||||
| FaxNumber: | 4233926624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 08/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 13341 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 39096741 | 05 | TN | MEDICAID | 1447283395 | 05 | VA | MEDICAID |