Healthcare Provider Details

I. General information

NPI: 1790929438
Provider Name (Legal Business Name): TARA LOVETT DETTRA L.M., C.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1093 A1A BEACH BLVD PMB 285
SAINT AUGUSTINE FL
32080-6733
US

IV. Provider business mailing address

1093 A1A BEACH BLVD PMB 285
SAINT AUGUSTINE FL
32080-6733
US

V. Phone/Fax

Practice location:
  • Phone: 904-540-7994
  • Fax: 904-471-4980
Mailing address:
  • Phone: 904-540-7994
  • Fax: 904-471-4980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW 227
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: