Provider Demographics
NPI:1689353146
Name:COLLEDGE, TARA DAWN (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DAWN
Last Name:COLLEDGE
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 1:275 W 200 N
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-5009
Mailing Address - Country:US
Mailing Address - Phone:801-836-0628
Mailing Address - Fax:
Practice Address - Street 1:5587 W HIDDEN DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-9139
Practice Address - Country:US
Practice Address - Phone:801-836-0628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT48497794405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner