Healthcare Provider Details

I. General information

NPI: 1699378398
Provider Name (Legal Business Name): TARA NICOLE LESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 JOHN NORMAN ST
CHARLESTON WV
25301-1258
US

IV. Provider business mailing address

5088 WASHINGTON ST W
CHARLESTON WV
25313-1536
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-4164
  • Fax:
Mailing address:
  • Phone: 681-217-2081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: