Provider Demographics
NPI:1417443433
Name:MAINIERI, TARA LAINE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LAINE
Last Name:MAINIERI
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-4626
Mailing Address - Country:US
Mailing Address - Phone:845-331-3131
Mailing Address - Fax:845-802-7362
Practice Address - Street 1:105 MARYS AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5848
Practice Address - Country:US
Practice Address - Phone:845-338-2500
Practice Address - Fax:845-802-7362
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05351693Medicaid