Healthcare Provider Details

I. General information

NPI: 1407563455
Provider Name (Legal Business Name): TARIS A YEBOAH PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 DILIGENCE DR STE 206
NEWPORT NEWS VA
23606-4272
US

IV. Provider business mailing address

PO BOX 33
MIDLOTHIAN VA
23113-0033
US

V. Phone/Fax

Practice location:
  • Phone: 757-310-6900
  • Fax:
Mailing address:
  • Phone: 804-594-5325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024185498
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: