Healthcare Provider Details

I. General information

NPI: 1629738778
Provider Name (Legal Business Name): TARA LA-KESSA PARKS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 8TH AVE SE
CAIRO GA
39828-3126
US

IV. Provider business mailing address

651 8TH AVE SE
CAIRO GA
39828-3126
US

V. Phone/Fax

Practice location:
  • Phone: 904-352-5767
  • Fax:
Mailing address:
  • Phone: 904-352-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN1225181
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: