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General NPI Number Information
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NPI Number | 1841946613
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Entity Type | Individual
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Provider Name | TARA LYNN MARTIN APRN
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Gender | Female
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Dates
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Enumeration Date | 03/01/2022
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Last Update Date | 03/01/2022
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Provider Practice Location Address
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Address Line | 133 SPINDER DR
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City | EAST PEORIA
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State | IL
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Zip | 61611-0016
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Country | US
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Telephone | 219-545-2255
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Fax |
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Provider Business Mailing Address
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Address Line | 9384 W 107TH LN
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City | SAINT JOHN
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State | IN
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Zip | 46373-8613
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Country | US
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Telephone | 219-545-2255
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209022764
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License Number State | IL
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