MEDICARE: MRS. TARA OWENS

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	163WP0200X	Pediatric Registered Nurse	4704296571	MI

General Provider Information

NPI Number	:	1972934990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA OWENS

Provider Business Mailing Address
First Line	:	5206 SPINNING WHEEL DR
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-4228
Country	:	US
Telephone Number	:	810-922-9695
Fax Number	:

Provider Business Practice Location Address
First Line	:	5206 SPINNING WHEEL DR
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-4228
Country	:	US
Telephone Number	:	810-922-9695
Fax Number	:

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

Provider Enumeration Date	:	12/01/2013
Last Update Date	:	12/01/2013

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