Healthcare Provider Details

I. General information

NPI: 1427527290
Provider Name (Legal Business Name): TARA L EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TARA WHEELER

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 N YELLOW SPRINGS ST
SPRINGFIELD OH
45504-2463
US

IV. Provider business mailing address

3210 N STATE ROUTE 560
URBANA OH
43078-9369
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.369924
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.026062
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: