Provider Demographics
NPI:1669654695
Name:VAN EEDE, TARA JAMES (LVN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JAMES
Last Name:VAN EEDE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 ROSWELL AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-4213
Mailing Address - Country:US
Mailing Address - Phone:562-438-5679
Mailing Address - Fax:
Practice Address - Street 1:456 ELM AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-2426
Practice Address - Country:US
Practice Address - Phone:562-437-6717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 225400000X
CAVN 231781164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner