Basic Information
| Provider Information | |||||||||
| NPI: | 1497330559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | TABITHA | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN-MSN, FNP-BC, CCRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3108 S ERIN LN | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640552760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162560750 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4401 WORNALL RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169322000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2021 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC0200X | 2021037463 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 163WC0200X | 2015019457 | MO | Y | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
No ID Information.