Provider Demographics
NPI:1578683918
Name:RICHARDSON, TARAI ELIZABETH (LPN)
Entity Type:Individual
Prefix:
First Name:TARAI
Middle Name:ELIZABETH
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TARAI
Other - Middle Name:ELIZABETH
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1405 BENSON DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-4604
Mailing Address - Country:US
Mailing Address - Phone:937-222-0433
Mailing Address - Fax:
Practice Address - Street 1:1405 BENSON DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-4604
Practice Address - Country:US
Practice Address - Phone:937-222-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 093961164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2356025Medicaid