MEDICARE: TARA ROSE YOUNG

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	363LP0200X	Pediatric Nurse Practitioner	4704257569	MI

General Provider Information

NPI Number	:	1851128201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA ROSE YOUNG

Provider Business Mailing Address
First Line	:	6444 LOS ALTOS DR NE
Second Line	:
City	:	ROCKFORD
State	:	MI
Zip	:	49341-8106
Country	:	US
Telephone Number	:	616-970-2888
Fax Number	:

Provider Business Practice Location Address
First Line	:	6444 LOS ALTOS DR NE
Second Line	:
City	:	ROCKFORD
State	:	MI
Zip	:	49341-8106
Country	:	US
Telephone Number	:	616-970-2888
Fax Number	:

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

Provider Enumeration Date	:	09/18/2024
Last Update Date	:	09/18/2024

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Directions to “ TARA ROSE YOUNG ” Practice Location

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