Provider Demographics
NPI:1790164705
Name:HEDGE, TARA (LPN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HEDGE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:698 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:MULLENS
Mailing Address - State:WV
Mailing Address - Zip Code:25882-1347
Mailing Address - Country:US
Mailing Address - Phone:419-610-8264
Mailing Address - Fax:
Practice Address - Street 1:698 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MULLENS
Practice Address - State:WV
Practice Address - Zip Code:25882-1347
Practice Address - Country:US
Practice Address - Phone:419-610-8264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34801164W00000X
OHPN.130012-M-IV164W00000X
KY2046163164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse