=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114683810
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA B CUNNINGHAM APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2021
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6265 ROCK CHALK DR STE 1500
-----------------------------------------------------
City | LAWRENCE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66049-5232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-843-9125
-----------------------------------------------------
Fax | 785-505-5312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1808 CARMEL DR
-----------------------------------------------------
City | LAWRENCE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66047-1852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-350-2626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 53-80585
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------