Provider Demographics
NPI:1114655453
Name:HUBLER, TARA MICHELLE (PNP-AC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELLE
Last Name:HUBLER
Suffix:
Gender:F
Credentials:PNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 JEWELL ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-5207
Mailing Address - Country:US
Mailing Address - Phone:423-794-8777
Mailing Address - Fax:
Practice Address - Street 1:1405 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1060
Practice Address - Country:US
Practice Address - Phone:423-794-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-14
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN314312363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics