Healthcare Provider Details

I. General information

NPI: 1417380312
Provider Name (Legal Business Name): TARESA PITTMAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 SLEEPY HOLLOW DR SUITE 204 BUNKER HILL BUILDING
MIDDLETOWN DE
19709-5846
US

IV. Provider business mailing address

8 BORDEAUX BLVD
NEWARK DE
19702
US

V. Phone/Fax

Practice location:
  • Phone: 302-365-0384
  • Fax:
Mailing address:
  • Phone: 302-365-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberL8-0000124
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: