Healthcare Provider Details

I. General information

NPI: 1417348558
Provider Name (Legal Business Name): TARA I MCKENNA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA F ROY RN

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S MAIN ST STE A
WOLFEBORO NH
03894-4455
US

IV. Provider business mailing address

240 S MAIN ST
WOLFEBORO NH
03894-4455
US

V. Phone/Fax

Practice location:
  • Phone: 603-569-7574
  • Fax: 603-569-7582
Mailing address:
  • Phone: 603-569-7574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number054907-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: