Provider Demographics
NPI:1508450057
Name:AVELLA, TARA MARIE (APRN FNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:AVELLA
Suffix:
Gender:F
Credentials:APRN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 HAMBURG TPKE STE 21
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 HAMBURG TPKE STE 21
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2132
Practice Address - Country:US
Practice Address - Phone:973-365-4318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR17158000207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology