Healthcare Provider Details

I. General information

NPI: 1255877957
Provider Name (Legal Business Name): TARA MCKITTRICK BRAEMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA MCKITTRICK BRAEMER

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 LIBERTY ST
REDDING CA
96001-0811
US

IV. Provider business mailing address

1441 LIBERTY ST
REDDING CA
96001-0811
US

V. Phone/Fax

Practice location:
  • Phone: 530-226-1726
  • Fax:
Mailing address:
  • Phone: 530-226-1726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95005845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: