=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134226699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA LORENCE VANBENNEKOM DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 KINGSLEY LAKE DRIVE SUITE #603
-----------------------------------------------------
City | ST. AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-5437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 ST. JOHNS FOREST BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-5796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | OS 8054
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------