Provider Demographics
NPI:1679069561
Name:ROBERTSON, TARA A (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:A
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 VALLEY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5205
Mailing Address - Country:US
Mailing Address - Phone:203-863-4210
Mailing Address - Fax:203-622-1872
Practice Address - Street 1:15 VALLEY DR STE 200
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831
Practice Address - Country:US
Practice Address - Phone:203-863-4210
Practice Address - Fax:203-622-1872
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily