Provider Demographics
NPI:1013461524
Name:BOATWRIGHT, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BOATWRIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 RIVER OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3281
Mailing Address - Country:US
Mailing Address - Phone:386-585-0365
Mailing Address - Fax:
Practice Address - Street 1:8 RIVER OAKS WAY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3281
Practice Address - Country:US
Practice Address - Phone:386-585-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL133NN1002X
FL305728146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education