Provider Demographics
NPI:1760970263
Name:MANSIUS, TARA JEANINE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JEANINE
Last Name:MANSIUS
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 1:515 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2938
Mailing Address - Country:US
Mailing Address - Phone:360-600-2008
Mailing Address - Fax:
Practice Address - Street 1:5319 S 500 E STE C
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7218
Practice Address - Country:US
Practice Address - Phone:801-516-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD10189489176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife