=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740493519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA LYNETTE PAHNKE RN, APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113B BERRY AVE
-----------------------------------------------------
City | GREER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29651-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-989-0230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42 AYERSDALE DR
-----------------------------------------------------
City | TAYLORS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29687-5500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-313-8472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 3128
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------