Healthcare Provider Details

I. General information

NPI: 1205364007
Provider Name (Legal Business Name): TARA LYNN NICHOLS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA LYNN WAGNER

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 11/23/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 6TH ST SW
CANTON OH
44710-1702
US

IV. Provider business mailing address

2600 6TH ST SW STE A2-800
CANTON OH
44710-1702
US

V. Phone/Fax

Practice location:
  • Phone: 330-363-1342
  • Fax:
Mailing address:
  • Phone: 330-363-1342
  • Fax: 330-363-1361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number365623
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.020528
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: