Provider Demographics
NPI:1326282138
Name:DOMMERT-HARRISON, TARA LYNN (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN
Last Name:DOMMERT-HARRISON
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:GOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IDMT
Mailing Address - Street 1:1317 SUMMERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-4709
Mailing Address - Country:US
Mailing Address - Phone:813-758-5469
Mailing Address - Fax:
Practice Address - Street 1:2900 DOOLITTLE DR
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4821
Practice Address - Country:US
Practice Address - Phone:605-385-3433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians