Provider Demographics
NPI:1730983537
Name:HENNINGER, TABITHA LYNETTE
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:LYNETTE
Last Name:HENNINGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:LYNETTE
Other - Last Name:WILLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1721 S PECAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5234
Mailing Address - Country:US
Mailing Address - Phone:918-693-1501
Mailing Address - Fax:
Practice Address - Street 1:1721 S PECAN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5234
Practice Address - Country:US
Practice Address - Phone:918-693-1501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator