Healthcare Provider Details

I. General information

NPI: 1649991126
Provider Name (Legal Business Name): TARA LEIGH SIMON DNP, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 JACKSON ST
PETOSKEY MI
49770-2220
US

IV. Provider business mailing address

602 JACKSON ST
PETOSKEY MI
49770-2220
US

V. Phone/Fax

Practice location:
  • Phone: 231-348-2795
  • Fax: 231-348-2031
Mailing address:
  • Phone: 231-348-2795
  • Fax: 231-348-2031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number4704326900
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704326900
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: