Provider Demographics
NPI:1407563455
Name:YEBOAH, TARIS A (PMHNP)
Entity Type:Individual
Prefix:
First Name:TARIS
Middle Name:A
Last Name:YEBOAH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-0033
Mailing Address - Country:US
Mailing Address - Phone:804-594-5325
Mailing Address - Fax:
Practice Address - Street 1:825 DILIGENCE DR STE 206
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4272
Practice Address - Country:US
Practice Address - Phone:757-310-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185498363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty