Healthcare Provider Details

I. General information

NPI: 1063979896
Provider Name (Legal Business Name): TARA JOAN ANP AND GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 GRAND CONCOURSE
BRONX NY
10453-4303
US

IV. Provider business mailing address

1434 WILLIAMSBRIDGE RD FL 2
BRONX NY
10461-2507
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-7295
  • Fax: 718-299-6797
Mailing address:
  • Phone: 718-618-0401
  • Fax: 347-479-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberF340417
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF302878
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: