Provider Demographics
NPI:1114790201
Name:GAILLARD, TAMAR KEREN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TAMAR
Middle Name:KEREN
Last Name:GAILLARD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 PACIFIC AVE APT D
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-8221
Mailing Address - Country:US
Mailing Address - Phone:917-346-8357
Mailing Address - Fax:
Practice Address - Street 1:11844 ROCK LANDING DR STE C
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4202
Practice Address - Country:US
Practice Address - Phone:757-736-0723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185396363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty