Provider Demographics
NPI:1336906486
Name:HATLEY, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HATLEY
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 1:1638 COUNTY ROAD 467
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2976
Mailing Address - Country:US
Mailing Address - Phone:573-300-5394
Mailing Address - Fax:
Practice Address - Street 1:1638 COUNTY ROAD 467
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2976
Practice Address - Country:US
Practice Address - Phone:573-300-5394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor