Provider Demographics
NPI:1679601413
Name:GRESHAM, TARA NICOLE (HS/SF-IDC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:NICOLE
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:HS/SF-IDC
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:NICOLE
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10565 COUNTY ROAD 1
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-5932
Mailing Address - Country:US
Mailing Address - Phone:727-593-4453
Mailing Address - Fax:
Practice Address - Street 1:1050 REGISTER ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-2421
Practice Address - Country:US
Practice Address - Phone:843-740-3147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No171000000XOther Service ProvidersMilitary Health Care Provider
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic