Provider Demographics
NPI:1306044185
Name:JEFFERSON, TARA CHAMINE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:CHAMINE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 NORTHUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3111
Mailing Address - Country:US
Mailing Address - Phone:716-896-4567
Mailing Address - Fax:
Practice Address - Street 1:34 BENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-1761
Practice Address - Country:US
Practice Address - Phone:716-986-9199
Practice Address - Fax:716-835-9357
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY627249163WA2000X, 163WM0705X
NY283810164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No164W00000XNursing Service ProvidersLicensed Practical Nurse