Provider Demographics
NPI:1336266550
Name:ENLOW, TARA B (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:B
Last Name:ENLOW
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 INTERCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-6011
Mailing Address - Country:US
Mailing Address - Phone:662-862-9040
Mailing Address - Fax:662-409-2102
Practice Address - Street 1:204 INTERCHANGE DR
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-6011
Practice Address - Country:US
Practice Address - Phone:662-862-9040
Practice Address - Fax:662-409-2102
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860076363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04103589Medicaid
MS500001929Medicare ID - Type Unspecified
MS04103589Medicaid