Healthcare Provider Details

I. General information

NPI: 1417443433
Provider Name (Legal Business Name): TARA LAINE MAINIERI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MARYS AVE
KINGSTON NY
12401-5848
US

IV. Provider business mailing address

396 BROADWAY
KINGSTON NY
12401-4626
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-2500
  • Fax: 845-802-7362
Mailing address:
  • Phone: 845-331-3131
  • Fax: 845-802-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343244
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: