Healthcare Provider Details

I. General information

NPI: 1386435139
Provider Name (Legal Business Name): TARA HANNAH SHOULDIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 08/12/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

110 ELM ST
PROVIDENCE RI
02903-4626
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number80652
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN04746
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: