Provider Demographics
NPI:1891288031
Name:HERTZ, TARA LEIGH (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LEIGH
Last Name:HERTZ
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LEIGH
Other - Last Name:ILSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:39 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8031
Mailing Address - Country:US
Mailing Address - Phone:631-591-7400
Mailing Address - Fax:
Practice Address - Street 1:39 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-591-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431384363LA2100X
NY581597163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse