=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740736156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARRA LEANI BAKER MSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2016
-----------------------------------------------------
Last Update Date | 03/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1249 FAIRVIEW AVE SE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-2534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-239-1146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4060
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97302-1060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-239-1146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 210180
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 201701173NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 21994
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 201701172RN
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------