Provider Demographics
NPI:1215560677
Name:MEREDITH, TARA (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MEREDITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PEMBERTON CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-5514
Mailing Address - Country:US
Mailing Address - Phone:731-394-1145
Mailing Address - Fax:844-374-0233
Practice Address - Street 1:718 GOODWIN LN
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1400
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014335208000000X, 363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics