Provider Demographics
NPI:1366828311
Name:MCCLINTOCK, TARA LEA (CNP-AC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LEA
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:CNP-AC
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LEA
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:1 PERKINS SQ
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44308-1063
Mailing Address - Country:US
Mailing Address - Phone:330-543-6060
Mailing Address - Fax:330-543-6069
Practice Address - Street 1:1 PERKINS SQ
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1063
Practice Address - Country:US
Practice Address - Phone:330-543-6060
Practice Address - Fax:330-543-6069
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.17892-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1366828311Medicaid