Provider Demographics
NPI:1629738778
Name:PARKS, TARA LA-KESSA (LPN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LA-KESSA
Last Name:PARKS
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 1:651 8TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-3126
Mailing Address - Country:US
Mailing Address - Phone:904-352-5767
Mailing Address - Fax:
Practice Address - Street 1:651 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-3126
Practice Address - Country:US
Practice Address - Phone:904-352-5767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1225181164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse