Provider Demographics
NPI:1013162346
Name:ACCAVALLO, TARA (FNP-BC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ACCAVALLO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2257
Mailing Address - Country:US
Mailing Address - Phone:631-846-6594
Mailing Address - Fax:
Practice Address - Street 1:5036 JERICHO TPKE STE 207
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2812
Practice Address - Country:US
Practice Address - Phone:631-486-8372
Practice Address - Fax:631-486-8374
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY454839163W00000X
NYF353276363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care