Healthcare Provider Details

I. General information

NPI: 1285341826
Provider Name (Legal Business Name): TARA NICOLE KIDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 MAR WALT DR STE 2013
FORT WALTON BEACH FL
32547-6756
US

IV. Provider business mailing address

4400 E HIGHWAY 20 STE 2013
NICEVILLE FL
32578-8779
US

V. Phone/Fax

Practice location:
  • Phone: 817-354-5200
  • Fax: 773-492-8765
Mailing address:
  • Phone: 850-797-2598
  • Fax: 773-492-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1098257
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11027520
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: