Healthcare Provider Details

I. General information

NPI: 1053803353
Provider Name (Legal Business Name): TARA IRENE COLELLA NIESEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 POWELL ST STE 507
NORRISTOWN PA
19401-3352
US

IV. Provider business mailing address

PO BOX 789967
PHILADELPHIA PA
19178-9967
US

V. Phone/Fax

Practice location:
  • Phone: 484-622-7940
  • Fax: 484-622-7950
Mailing address:
  • Phone: 484-622-7395
  • Fax: 484-622-7399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP018653
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: