Healthcare Provider Details

I. General information

NPI: 1760970263
Provider Name (Legal Business Name): TARA JEANINE MANSIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5319 S 500 E STE C
OGDEN UT
84405-7218
US

IV. Provider business mailing address

515 S CENTER ST
OREGON CITY OR
97045-2938
US

V. Phone/Fax

Practice location:
  • Phone: 801-516-0576
  • Fax:
Mailing address:
  • Phone: 360-600-2008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberDEM-LD10189489
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: