Provider Demographics
NPI:1447645544
Name:VACHUSKA, TABITHA
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:VACHUSKA
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 1:1200 W BROADWAY AVE
Mailing Address - Street 2:SUITE # 160
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2572
Mailing Address - Country:US
Mailing Address - Phone:612-353-6308
Mailing Address - Fax:612-886-2708
Practice Address - Street 1:1200 W BROADWAY AVE
Practice Address - Street 2:SUITE # 160
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2572
Practice Address - Country:US
Practice Address - Phone:612-353-6308
Practice Address - Fax:612-886-2708
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47-29514363747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant