Provider Demographics
NPI:1679204473
Name:GREGORY, TARA ELAINE (LPN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ELAINE
Last Name:GREGORY
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 1:363 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-5302
Mailing Address - Country:US
Mailing Address - Phone:502-689-5509
Mailing Address - Fax:
Practice Address - Street 1:363 1ST ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-5302
Practice Address - Country:US
Practice Address - Phone:502-689-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335328-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse