Provider Demographics
NPI:1154076495
Name:HERNDON, TARA LEEANNE (APRN)
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:LEEANNE
Last Name:HERNDON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11761 BEACH BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6699
Mailing Address - Country:US
Mailing Address - Phone:904-642-3304
Mailing Address - Fax:904-642-8375
Practice Address - Street 1:11761 BEACH BLVD STE 8
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6699
Practice Address - Country:US
Practice Address - Phone:904-642-3304
Practice Address - Fax:904-642-8375
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11017994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily