Provider Demographics
NPI:1235905670
Name:TARBORO, SYREETA NICOLE (LPN)
Entity Type:Individual
Prefix:
First Name:SYREETA
Middle Name:NICOLE
Last Name:TARBORO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16703 GOVERNOR BRIDGE RD APT 304C
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3679
Mailing Address - Country:US
Mailing Address - Phone:215-960-1171
Mailing Address - Fax:
Practice Address - Street 1:3725 PROVIDENCE POINT DR SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-7219
Practice Address - Country:US
Practice Address - Phone:215-960-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP54574164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse