Provider Demographics
NPI:1851934988
Name:RIDGEWAY, TARA MICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELLE
Last Name:RIDGEWAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 E HUNT HWY STE 103-140
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5224
Mailing Address - Country:US
Mailing Address - Phone:480-605-4670
Mailing Address - Fax:
Practice Address - Street 1:530 E HUNT HWY STE 103-140
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5224
Practice Address - Country:US
Practice Address - Phone:480-605-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019368363LP0808X
AZ231483363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health