Provider Demographics
NPI:1265877989
Name:BLAIR, TARA LESLIE (DNP, APRN, CCNS)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:LESLIE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:DNP, APRN, CCNS
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:JACQUELINE
Other - Last Name:LESLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP, RN
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7818
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:227 FALCON DR STE 101
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9792
Practice Address - Country:US
Practice Address - Phone:859-497-5135
Practice Address - Fax:859-497-5140
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007961364SC0200X, 364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100257800Medicaid
KY7100257800Medicaid