Healthcare Provider Details

I. General information

NPI: 1649309105
Provider Name (Legal Business Name): TARA A SHEALY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 ALTA RD SUITE 6100
SAN DIEGO CA
92158-0001
US

IV. Provider business mailing address

11272 CORTE PLAYA MADERA
SAN DIEGO CA
92124-4137
US

V. Phone/Fax

Practice location:
  • Phone: 619-671-6533
  • Fax:
Mailing address:
  • Phone: 858-292-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number392596
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: