Healthcare Provider Details

I. General information

NPI: 1629219233
Provider Name (Legal Business Name): TARA K WOODLAND CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 5TH AVE N
BAYPORT MN
55003-1201
US

IV. Provider business mailing address

312 5TH AVE N
BAYPORT MN
55003-1201
US

V. Phone/Fax

Practice location:
  • Phone: 651-421-2914
  • Fax:
Mailing address:
  • Phone: 651-421-2914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9499
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR1735015
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: