Provider Demographics
NPI:1245059450
Name:WIESNER, TARA (MSN,CCM)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WIESNER
Suffix:
Gender:F
Credentials:MSN,CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1852 PARKDALE CIR S
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-2407
Mailing Address - Country:US
Mailing Address - Phone:720-933-3039
Mailing Address - Fax:
Practice Address - Street 1:12337 JONES RD STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4844
Practice Address - Country:US
Practice Address - Phone:303-570-0134
Practice Address - Fax:877-747-9662
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0140447163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management