Healthcare Provider Details

I. General information

NPI: 1528323078
Provider Name (Legal Business Name): TARA BLAKE COMARDELLE CRNA, MNNA, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA MARIE BLAKE

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12293 OLD MILLSTONE DR.
GEISMAR LA
70734
US

IV. Provider business mailing address

12293 OLD MILLSTONE DR
GEISMAR LA
70734-3237
US

V. Phone/Fax

Practice location:
  • Phone: 407-748-3405
  • Fax:
Mailing address:
  • Phone: 407-748-1602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberTAP002845
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: