Provider Demographics
NPI:1710251004
Name:FERNALLD, TARA EILEEN (LAC, DAOM)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:EILEEN
Last Name:FERNALLD
Suffix:
Gender:F
Credentials:LAC, DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER
Mailing Address - Street 2:UNIT 33100
Mailing Address - City:APO
Mailing Address - State:OVERSEAS MILITARY TREATMENT FACILITY
Mailing Address - Zip Code:09180
Mailing Address - Country:AE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 CELIA CT
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-7153
Practice Address - Country:US
Practice Address - Phone:678-793-3834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-04
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3448171100000X
GA225171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist