Healthcare Provider Details

I. General information

NPI: 1356082499
Provider Name (Legal Business Name): TARA NICOLE COADY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 REYNOLDS ST STE 100
MONROE NC
28112-4376
US

IV. Provider business mailing address

724 BAYSHORE DR
LODA IL
60948-9738
US

V. Phone/Fax

Practice location:
  • Phone: 704-289-5443
  • Fax: 704-283-7655
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: