Provider Demographics
NPI:1285005470
Name:FORSTIE, TARA (NP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FORSTIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:J
Other - Last Name:FREDRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:515 E CAREFREE HWY # 299
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8839
Mailing Address - Country:US
Mailing Address - Phone:602-769-1137
Mailing Address - Fax:
Practice Address - Street 1:19829 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4001
Practice Address - Country:US
Practice Address - Phone:602-769-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN00000099202363LA2100X
CO1161363LA2100X
NDR53837363LP0200X
MN9886363LP0200X
AZAP8273363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care