MEDICARE: MRS. TARA RENEE BROZ RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN. 119620	OH
2	163W00000X	Registered Nurse	RN 350383	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225078777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA RENEE BROZ RN

Provider Business Mailing Address
First Line	:	1411 STONE LEDGE CT
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-1259
Country	:	US
Telephone Number	:	330-896-8967
Fax Number	:

Provider Business Practice Location Address
First Line	:	1411 STONE LEDGE CT
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-1259
Country	:	US
Telephone Number	:	330-896-8967
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	06/19/2009

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