Provider Demographics
NPI:1053899807
Name:CLAYTON, TABITHA FAITH (ARNP, CNM)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:FAITH
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2031
Mailing Address - Country:US
Mailing Address - Phone:321-841-5281
Mailing Address - Fax:407-648-9879
Practice Address - Street 1:83 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2031
Practice Address - Country:US
Practice Address - Phone:321-841-5281
Practice Address - Fax:407-648-9879
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9377992367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102620100Medicaid