Provider Demographics
NPI:1619112182
Name:KNACK-MORENO, TARA LOUISE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:LOUISE
Last Name:KNACK-MORENO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:PARKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12768-0037
Mailing Address - Country:US
Mailing Address - Phone:845-807-1877
Mailing Address - Fax:
Practice Address - Street 1:1032 COOLEY ROAD
Practice Address - Street 2:
Practice Address - City:PARKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12768-0037
Practice Address - Country:US
Practice Address - Phone:845-807-1877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285092-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse