Provider Demographics
NPI:1578252920
Name:HOLM, TARA LEE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LEE
Last Name:HOLM
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 1:5 SPRING LN APT J7
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3382
Mailing Address - Country:US
Mailing Address - Phone:860-921-6028
Mailing Address - Fax:
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-8122
Practice Address - Country:US
Practice Address - Phone:888-793-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT163878163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse