Provider Demographics
NPI:1780044347
Name:BURICH, TARA MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:BURICH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:2500 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:920-830-6877
Practice Address - Fax:920-738-4792
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6875363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily