Healthcare Provider Details

I. General information

NPI: 1093034696
Provider Name (Legal Business Name): TARA GILLETT CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TARA CORNELSEN

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL # GE07
MADERA CA
93636-8761
US

IV. Provider business mailing address

9300 VALLEY CHILDRENS PL # GE07
MADERA CA
93636-8761
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-6277
  • Fax:
Mailing address:
  • Phone: 559-392-8812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number19381
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: