MEDICARE: MRS. TARA LOVETT DETTRA L.M., C.P.M.

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	176B00000X	Midwife	MW 227	FL

General Provider Information

NPI Number	:	1790929438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA LOVETT DETTRA L.M., C.P.M.

Provider Business Mailing Address
First Line	:	1093 A1A BEACH BLVD
Second Line	:	PMB 285
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-6733
Country	:	US
Telephone Number	:	904-540-7994
Fax Number	:	904-471-4980

Provider Business Practice Location Address
First Line	:	1093 A1A BEACH BLVD
Second Line	:	PMB 285
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-6733
Country	:	US
Telephone Number	:	904-540-7994
Fax Number	:	904-471-4980

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

Provider Enumeration Date	:	04/24/2009
Last Update Date	:	04/24/2009

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