Healthcare Provider Details

I. General information

NPI: 1003635673
Provider Name (Legal Business Name): TARA DALE BRANCH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 N FORGE ST
AKRON OH
44304-1468
US

IV. Provider business mailing address

723 BERWICK CT
COPLEY OH
44321-1494
US

V. Phone/Fax

Practice location:
  • Phone: 330-376-1043
  • Fax:
Mailing address:
  • Phone: 330-256-2561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberAPRN.CNP.037647
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: