Healthcare Provider Details

I. General information

NPI: 1285576157
Provider Name (Legal Business Name): TARA NOELLE FONTANA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 E CAMELBACK RD
PHOENIX AZ
85016-4502
US

IV. Provider business mailing address

3126 E CAMELBACK RD
PHOENIX AZ
85016-4502
US

V. Phone/Fax

Practice location:
  • Phone: 602-957-1716
  • Fax:
Mailing address:
  • Phone: 602-957-1716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO003261
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: