Provider Demographics
NPI:1780649137
Name:DWELLEY, TARA CL (CNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:CL
Last Name:DWELLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 MILL ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:ME
Mailing Address - Zip Code:04668-3344
Mailing Address - Country:US
Mailing Address - Phone:207-796-5503
Mailing Address - Fax:207-796-5528
Practice Address - Street 1:136 MILL ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:ME
Practice Address - Zip Code:04668-3344
Practice Address - Country:US
Practice Address - Phone:207-796-5503
Practice Address - Fax:207-796-5528
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER049268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431937699Medicaid
NP5130Medicare ID - Type Unspecified
Q52102Medicare UPIN