Healthcare Provider Details

I. General information

NPI: 1497918163
Provider Name (Legal Business Name): TARA LYNN WEATHERS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA LYNN WOMBOLD

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 W MILLER ST
ORLANDO FL
32806-2031
US

IV. Provider business mailing address

2699 LEE RD SUITE 510
WINTER PARK FL
32789-1753
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-9792
  • Fax:
Mailing address:
  • Phone: 407-896-9500
  • Fax: 407-896-9585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9182816
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: