Healthcare Provider Details

I. General information

NPI: 1033555966
Provider Name (Legal Business Name): TARA JANAE LITTLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA JANAE CLEVELAND FNP

II. Dates (important events)

Enumeration Date: 05/19/2013
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 PROVIDENT DR STE A
WARSAW IN
46580-3265
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 574-269-8383
  • Fax: 260-479-2911
Mailing address:
  • Phone: 260-479-3513
  • Fax: 260-479-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71004739A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004739A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: