Healthcare Provider Details

I. General information

NPI: 1104003862
Provider Name (Legal Business Name): TARA LYNN KAUTZER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA LYNN MEREDITH CRNA

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 HOGBACK RD STE 5A
ANN ARBOR MI
48105-9750
US

IV. Provider business mailing address

3911 ROCHESTER RD
TROY MI
48083-5246
US

V. Phone/Fax

Practice location:
  • Phone: 734-263-2417
  • Fax:
Mailing address:
  • Phone: 248-689-7740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704239859
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: