Provider Demographics
NPI:1518260397
Name:CASELLA, TARA (CPNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CASELLA
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 1ST AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02129-3109
Mailing Address - Country:US
Mailing Address - Phone:617-952-5800
Mailing Address - Fax:
Practice Address - Street 1:300 1ST AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02129-3109
Practice Address - Country:US
Practice Address - Phone:617-952-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA267766363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics