Provider Demographics
NPI:1659093060
Name:FISHWILD, TARA LYNN (NP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:FISHWILD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 STONECREST BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6832
Mailing Address - Country:US
Mailing Address - Phone:629-220-0211
Mailing Address - Fax:629-220-0210
Practice Address - Street 1:300 STONECREST BLVD STE 250
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6832
Practice Address - Country:US
Practice Address - Phone:615-917-6020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32393363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty