Healthcare Provider Details

I. General information

NPI: 1861101842
Provider Name (Legal Business Name): TARA FACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10102 COUNTRY CLUB RD SE
CUMBERLAND MD
21502-8339
US

IV. Provider business mailing address

12603 LIMESTONE RD SE
CUMBERLAND MD
21502-8704
US

V. Phone/Fax

Practice location:
  • Phone: 301-777-2285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR252916
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: