Healthcare Provider Details

I. General information

NPI: 1922570282
Provider Name (Legal Business Name): TARA WILLIAMS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA DEBIASE

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOE FRANK HARRIS PKWY SE
CARTERSVILLE GA
30120-2129
US

IV. Provider business mailing address

2875 CRESCENT PKWY APT 1541
ATLANTA GA
30339-6293
US

V. Phone/Fax

Practice location:
  • Phone: 770-382-1530
  • Fax:
Mailing address:
  • Phone: 845-532-8091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number123240
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: