Provider Demographics
NPI:1497918163
Name:WEATHERS, TARA LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:WEATHERS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:WOMBOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2699 LEE RD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1753
Mailing Address - Country:US
Mailing Address - Phone:407-896-9500
Mailing Address - Fax:407-896-9585
Practice Address - Street 1:83 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2031
Practice Address - Country:US
Practice Address - Phone:321-843-9792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9182816367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000281100Medicaid
FLAM321ZMedicare PIN