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General NPI Number Information
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NPI Number | 1205364007
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Entity Type | Individual
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Provider Name | TARA LYNN NICHOLS CNP
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Gender | Female
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Dates
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Enumeration Date | 05/24/2017
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Last Update Date | 11/23/2022
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Provider Practice Location Address
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Address Line | 2600 6TH ST SW
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City | CANTON
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State | OH
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Zip | 44710-1702
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Country | US
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Telephone | 330-363-1342
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Fax |
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Provider Business Mailing Address
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Address Line | 2600 6TH ST SW STE A2-800
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City | CANTON
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State | OH
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Zip | 44710-1702
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Country | US
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Telephone | 330-363-1342
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Fax | 330-363-1361
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 365623
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | APRN.CNP.020528
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License Number State | OH
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