Provider Demographics
NPI:1164824421
Name:MEREDITH, TARA NICHOLE (ACNP-C)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:NICHOLE
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:ACNP-C
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:NICHOLE
Other - Last Name:BLACKMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:3 RICHLAND MEDICAL PARK DR STE 510
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6854
Practice Address - Country:US
Practice Address - Phone:803-296-2726
Practice Address - Fax:803-296-3319
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18921363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3137Medicaid
SCNP3137Medicaid