MEDICARE: TARA JO WILKINSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	26993	WV

General Provider Information

NPI Number	:	1366128720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA JO WILKINSON

Provider Business Mailing Address
First Line	:	1408 E CAMPBELL PARK DR
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25705-3057
Country	:	US
Telephone Number	:	681-378-8388
Fax Number	:

Provider Business Practice Location Address
First Line	:	1408 E CAMPBELL PARK DR
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25705-3057
Country	:	US
Telephone Number	:	681-378-8388
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2023
Last Update Date	:	06/22/2023

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