Provider Demographics
NPI:1760188502
Name:ELIZONDO, TARA JO (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:JO
Last Name:ELIZONDO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1522 W FRANK AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3334
Mailing Address - Country:US
Mailing Address - Phone:936-639-2384
Mailing Address - Fax:936-639-9888
Practice Address - Street 1:1522 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3334
Practice Address - Country:US
Practice Address - Phone:936-639-2384
Practice Address - Fax:936-639-9888
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1107727363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health