Provider Demographics
NPI:1275167835
Name:HART, TARA KEAVENY
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:KEAVENY
Last Name:HART
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 1:7214 BELLONA AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-1007
Mailing Address - Country:US
Mailing Address - Phone:410-608-7748
Mailing Address - Fax:
Practice Address - Street 1:10807 FALLS RD STE 200
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4595
Practice Address - Country:US
Practice Address - Phone:410-321-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-23
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR242665363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics