Provider Demographics
NPI:1033962634
Name:MICK, TARA JANE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JANE
Last Name:MICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:JANE
Other - Last Name:CHAPMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2259 HACKERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-6139
Mailing Address - Country:US
Mailing Address - Phone:304-406-8475
Mailing Address - Fax:
Practice Address - Street 1:28 N KANAWHA ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2714
Practice Address - Country:US
Practice Address - Phone:304-472-0528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care