Healthcare Provider Details

I. General information

NPI: 1356895353
Provider Name (Legal Business Name): TARA JO MOSES NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321B GREENVILLE ST
LAGRANGE GA
30241-3231
US

IV. Provider business mailing address

2522 WARM SPRINGS RD
COLUMBUS GA
31904-5640
US

V. Phone/Fax

Practice location:
  • Phone: 678-810-1955
  • Fax: 678-810-1955
Mailing address:
  • Phone: 706-322-9313
  • Fax: 706-322-9314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN232791
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: