Provider Demographics
NPI:1609479740
Name:STEPHAN, TARA LYNN
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:LYNN
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:STEPHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:919 STINSON DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:919 STINSON DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2136
Practice Address - Country:US
Practice Address - Phone:616-302-5994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X390200000X
MIF03210972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program