Provider Demographics
NPI:1689458358
Name:HOLLINGSWORTH, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HOLLINGSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 LAKOTA CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-4074
Mailing Address - Country:US
Mailing Address - Phone:704-726-4555
Mailing Address - Fax:
Practice Address - Street 1:4040 LAKOTA CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-4074
Practice Address - Country:US
Practice Address - Phone:704-726-4555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27810961343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)