Provider Demographics
NPI:1891036638
Name:TAVARES, TAHEERA A (LPN)
Entity Type:Individual
Prefix:
First Name:TAHEERA
Middle Name:A
Last Name:TAVARES
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 1:6348 WINCHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-8176
Mailing Address - Country:US
Mailing Address - Phone:203-901-9069
Mailing Address - Fax:
Practice Address - Street 1:6348 WINCHESTER PIKE
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-8176
Practice Address - Country:US
Practice Address - Phone:203-901-9069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH149059164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse