Healthcare Provider Details

I. General information

NPI: 1801378641
Provider Name (Legal Business Name): TARA LADAWN PHILLIPS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 W 7TH ST
WAKE VILLAGE TX
75501-6255
US

IV. Provider business mailing address

3515 RICHMOND RD
TEXARKANA TX
75503-0711
US

V. Phone/Fax

Practice location:
  • Phone: 903-831-4065
  • Fax: 903-831-4075
Mailing address:
  • Phone: 903-791-9355
  • Fax: 903-793-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1052397
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number225755
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0113302
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: