Healthcare Provider Details

I. General information

NPI: 1467178459
Provider Name (Legal Business Name): TARA WELCH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S BECKHAM AVE
TYLER TX
75701-1908
US

IV. Provider business mailing address

7005 WALDEN DR
TYLER TX
75703-0917
US

V. Phone/Fax

Practice location:
  • Phone: 903-597-0351
  • Fax:
Mailing address:
  • Phone: 903-343-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number669039
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1101443
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: