Provider Demographics
NPI:1457656449
Name:WILEY, TARA ANNE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ANNE
Last Name:WILEY
Suffix:
Gender:F
Credentials:RN
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 5199
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-5199
Mailing Address - Country:US
Mailing Address - Phone:325-658-6571
Mailing Address - Fax:325-653-0036
Practice Address - Street 1:612 S IRENE ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6629
Practice Address - Country:US
Practice Address - Phone:325-658-6571
Practice Address - Fax:325-653-0036
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX728367222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1396867966Medicaid