Provider Demographics
NPI:1104184845
Name:DEVILLE, TARA BOUDOIN (NP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:BOUDOIN
Last Name:DEVILLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3195 DOWLEN RD STE 105
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7272
Mailing Address - Country:US
Mailing Address - Phone:409-204-0257
Mailing Address - Fax:
Practice Address - Street 1:3195 DOWLEN RD STE 105
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706
Practice Address - Country:US
Practice Address - Phone:409-204-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX712309363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner