Provider Demographics
NPI:1437679156
Name:PROCTOR, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 PARADISE POINT LANE
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703
Mailing Address - Country:US
Mailing Address - Phone:321-460-7028
Mailing Address - Fax:
Practice Address - Street 1:2124 PARADISE POINT LN
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-9406
Practice Address - Country:US
Practice Address - Phone:321-460-7028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234863376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker