Provider Demographics
NPI:1225817661
Name:MCCOLLOCH, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MCCOLLOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MCCOLLOCH-LUSSIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1618 S LANE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2829
Mailing Address - Country:US
Mailing Address - Phone:206-459-9727
Mailing Address - Fax:
Practice Address - Street 1:1618 S LANE ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2829
Practice Address - Country:US
Practice Address - Phone:206-459-9727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60584747163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health