Healthcare Provider Details

I. General information

NPI: 1588337232
Provider Name (Legal Business Name): TARA SEKLE PETTUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 X ST
SACRAMENTO CA
95817-2214
US

IV. Provider business mailing address

4301 X ST
SACRAMENTO CA
95817-2214
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-5028
  • Fax:
Mailing address:
  • Phone: 210-323-7549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95203093
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95002263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: