Provider Demographics
NPI:1518383850
Name:MADISON, TARA LEE
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEE
Last Name:MADISON
Suffix:
Gender:F
Credentials:
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 2523
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-2523
Mailing Address - Country:US
Mailing Address - Phone:386-693-4883
Mailing Address - Fax:386-693-4892
Practice Address - Street 1:97 FLAGLER PLAZA DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-5965
Practice Address - Country:US
Practice Address - Phone:386-693-4883
Practice Address - Fax:386-693-4892
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-44-1424515246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other