Provider Demographics
NPI:1053962480
Name:WAMBAA, TABITHA
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:WAMBAA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E FESLER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4404
Mailing Address - Country:US
Mailing Address - Phone:805-922-6597
Mailing Address - Fax:
Practice Address - Street 1:115 E FESLER ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4404
Practice Address - Country:US
Practice Address - Phone:805-922-6597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41099167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician