Healthcare Provider Details

I. General information

NPI: 1821234832
Provider Name (Legal Business Name): TARA NOEL YOUNG-HODGE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PENNSYLVANIA AVE
CHARLESTON WV
25302-3351
US

IV. Provider business mailing address

4750 HEMPSTEAD STATION DR
KETTERING OH
45429-5164
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-2551
  • Fax:
Mailing address:
  • Phone: 800-875-0136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number48799
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: