Provider Demographics
NPI:1326392333
Name:STALEY, TARA LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:STALEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1756
Mailing Address - Country:US
Mailing Address - Phone:978-557-8800
Mailing Address - Fax:978-557-8856
Practice Address - Street 1:500 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1756
Practice Address - Country:US
Practice Address - Phone:978-557-8800
Practice Address - Fax:978-557-8856
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2270504363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner