Provider Demographics
NPI:1629761853
Name:ABBA, TARA (MS, RD, CNSC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ABBA
Suffix:
Gender:F
Credentials:MS, RD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2481 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-6307
Mailing Address - Country:US
Mailing Address - Phone:719-306-2426
Mailing Address - Fax:
Practice Address - Street 1:125 ADAMS ST
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-3211
Practice Address - Country:US
Practice Address - Phone:518-470-0866
Practice Address - Fax:518-380-6266
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009484133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered