Provider Demographics
NPI:1346554128
Name:HALLENBACK, TARA (LPN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HALLENBACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 WOODBURY RD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-3036
Mailing Address - Country:US
Mailing Address - Phone:516-761-0298
Mailing Address - Fax:
Practice Address - Street 1:372 WOODBURY RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3036
Practice Address - Country:US
Practice Address - Phone:516-761-0298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10-299641164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse