Healthcare Provider Details

I. General information

NPI: 1073474516
Provider Name (Legal Business Name): TARA COOKSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 N QUINCY AVE STE 1
OTTUMWA IA
52501-3810
US

IV. Provider business mailing address

1802 ALBIA RD
OTTUMWA IA
52501-3705
US

V. Phone/Fax

Practice location:
  • Phone: 641-683-4300
  • Fax:
Mailing address:
  • Phone: 641-683-4300
  • Fax: 641-683-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP49730
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: