Provider Demographics
NPI:1902350408
Name:TABOR, ENIANA JANE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ENIANA
Middle Name:JANE
Last Name:TABOR
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:ENIANA
Other - Middle Name:JANE
Other - Last Name:AGOLLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:289 GREAT ROAD
Mailing Address - Street 2:SUITE G1
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720
Mailing Address - Country:US
Mailing Address - Phone:978-679-1200
Mailing Address - Fax:978-486-4037
Practice Address - Street 1:289 GREAT ROAD
Practice Address - Street 2:SUITE G1
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720
Practice Address - Country:US
Practice Address - Phone:978-679-1200
Practice Address - Fax:978-486-4037
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2310374363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA020860Medicaid