Healthcare Provider Details

I. General information

NPI: 1306656665
Provider Name (Legal Business Name): TARYN KORNEGAY ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 774-441-6468
  • Fax:
Mailing address:
  • Phone: 800-225-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN2353243
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2353243
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: