Healthcare Provider Details

I. General information

NPI: 1013144534
Provider Name (Legal Business Name): LINDA KOVAC-TANTALO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1386 HATHAWAY DR
FARMINGTON NY
14425-8973
US

IV. Provider business mailing address

707 HAWKS NEST CIR
ROCHESTER NY
14626-4894
US

V. Phone/Fax

Practice location:
  • Phone: 585-396-4190
  • Fax:
Mailing address:
  • Phone: 585-738-9127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number401203
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: