Provider Demographics
NPI:1164748646
Name:KINNEY, TARA M (CRNA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:KINNEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DEXTER CT STE 104
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3419
Mailing Address - Country:US
Mailing Address - Phone:563-334-0234
Mailing Address - Fax:563-334-0235
Practice Address - Street 1:3400 DEXTER CT STE 104
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3419
Practice Address - Country:US
Practice Address - Phone:563-334-0234
Practice Address - Fax:563-334-0235
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1566983367500000X
390200000X
IL209009089367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP00849727OtherRAILROAD MEDICARE
IAENROLLEDMedicaid
IAENROLLEDMedicaid