Provider Demographics
NPI:1689281057
Name:BOLERJACK, TARA LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:BOLERJACK
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 1:2405 STONEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-1703
Mailing Address - Country:US
Mailing Address - Phone:740-501-7772
Mailing Address - Fax:
Practice Address - Street 1:2405 STONEBRIDGE DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-1703
Practice Address - Country:US
Practice Address - Phone:740-501-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK119548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily