Provider Demographics
NPI:1487207122
Name:WILLOUGHBY, TARA JANE (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JANE
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-1725
Mailing Address - Country:US
Mailing Address - Phone:406-532-8400
Mailing Address - Fax:406-224-4402
Practice Address - Street 1:81 W PARK ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1713
Practice Address - Country:US
Practice Address - Phone:406-497-9000
Practice Address - Fax:406-723-7117
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT142868363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health