Healthcare Provider Details

I. General information

NPI: 1992834253
Provider Name (Legal Business Name): TARA A CAPUANO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA TILLINGHAST NP

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DUDLEY ST
PROVIDENCE RI
02905-2401
US

IV. Provider business mailing address

101 DUDLEY ST
PROVIDENCE RI
02905-2401
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-1100
  • Fax:
Mailing address:
  • Phone: 401-274-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNPP33665
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPRN00272
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: