Basic Information
| Provider Information | |||||||||
| NPI: | 1962584375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMPSON | ||||||||
| FirstName: | TABITHA | ||||||||
| MiddleName: | DEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLAKE | ||||||||
| OtherFirstName: | TABITHA | ||||||||
| OtherMiddleName: | DEE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 230 | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478820230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2200 N SECTION ST STE A | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122684311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71001735B | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200317180A | 01 | IN | MEDICAID GROUP | OTHER | 200880570 | 05 | IN | MEDICAID | 200889400 | 01 | MEDICAID RURAL HEALTH-GROUP | OTHER |