Provider Demographics
NPI:1033555966
Name:LITTLE, TARA JANAE (FNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JANAE
Last Name:LITTLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:JANAE
Other - Last Name:CLEVELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3513
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:1205 PROVIDENT DR STE A
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3265
Practice Address - Country:US
Practice Address - Phone:574-269-8383
Practice Address - Fax:260-479-2911
Is Sole Proprietor?:No
Enumeration Date:2013-05-19
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004739A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201213790Medicaid
IN259990031Medicare PIN