Provider Demographics
NPI:1427655588
Name:LA SALLE, TARA NICOLE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:NICOLE
Last Name:LA SALLE
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 1:2235 CORBETT RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4909
Mailing Address - Country:US
Mailing Address - Phone:727-946-0785
Mailing Address - Fax:
Practice Address - Street 1:443 COUNTY RD 419 STE 1001
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32766
Practice Address - Country:US
Practice Address - Phone:407-366-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS60283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist