Healthcare Provider Details

I. General information

NPI: 1295080851
Provider Name (Legal Business Name): TARA SUE VANGUNDY CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA SUE RAY RN

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 OAKWOOD AVE
OAKWOOD OH
45419-2911
US

IV. Provider business mailing address

7073 CLYO RD
CENTERVILLE OH
45459-4816
US

V. Phone/Fax

Practice location:
  • Phone: 937-885-7163
  • Fax: 937-567-0670
Mailing address:
  • Phone: 937-435-5857
  • Fax: 937-912-4960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA13396
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: