Provider Demographics
NPI:1871862268
Name:ROBERTS, TARA M (LPN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3907 CHESTNUT OAK TRL
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45807-3113
Mailing Address - Country:US
Mailing Address - Phone:567-204-4837
Mailing Address - Fax:419-229-0006
Practice Address - Street 1:3907 CHESTNUT OAK TRL
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807-3113
Practice Address - Country:US
Practice Address - Phone:567-204-4837
Practice Address - Fax:419-229-0006
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH147299164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse