Provider Demographics
NPI:1598935595
Name:MONETTE, TARA (ARNP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MONETTE
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:765 IMAGE WAY
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8399
Practice Address - Country:US
Practice Address - Phone:386-774-7411
Practice Address - Fax:386-774-7412
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9179359363LF0000X
FLARNP-C9179359363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000643700Medicaid
FLAJ929YMedicare PIN