Provider Demographics
NPI:1275007775
Name:DALLES, TARA NICOLE (CCC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:NICOLE
Last Name:DALLES
Suffix:
Gender:F
Credentials:CCC
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:NICOLE
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:366 NEEDLES TRL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:366 NEEDLES TRL
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4655
Practice Address - Country:US
Practice Address - Phone:321-239-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No174N00000XOther Service ProvidersLactation Consultant, Non-RN