Healthcare Provider Details

I. General information

NPI: 1376565291
Provider Name (Legal Business Name): TARA DUPUY HERRERO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 N JASPER DR STE 1
FLAGSTAFF AZ
86001-1634
US

IV. Provider business mailing address

322 PLEASANT HILL RD
LANDRUM SC
29356-8727
US

V. Phone/Fax

Practice location:
  • Phone: 928-558-7001
  • Fax:
Mailing address:
  • Phone: 864-468-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2925652
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number293397
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: