Provider Demographics
NPI:1558667584
Name:NANNINGA, TARA (MSPT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:NANNINGA
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 N 26TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-4739
Mailing Address - Country:US
Mailing Address - Phone:402-477-3110
Mailing Address - Fax:402-477-4990
Practice Address - Street 1:4911 N 26TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-4739
Practice Address - Country:US
Practice Address - Phone:402-477-3110
Practice Address - Fax:402-477-4990
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019010863OtherSTATE OF MISSOURI
KS11-06260OtherSTATE OF KANSAS
NE1720OtherSTATE OF NE