Provider Demographics
NPI:1215578760
Name:FITZPATRICK, TARA ASHLEY
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ASHLEY
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-4023
Mailing Address - Country:US
Mailing Address - Phone:631-398-9717
Mailing Address - Fax:
Practice Address - Street 1:750 HICKSVILLE RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1328
Practice Address - Country:US
Practice Address - Phone:516-520-6000
Practice Address - Fax:516-796-6341
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY632582121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist