Provider Demographics
NPI:1497406987
Name:COPPOLA, TARA LYN (ND, MS, CES)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:LYN
Last Name:COPPOLA
Suffix:
Gender:F
Credentials:ND, MS, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 E MISSOURI AVE STE 850
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2790
Mailing Address - Country:US
Mailing Address - Phone:203-285-4137
Mailing Address - Fax:623-307-6767
Practice Address - Street 1:1130 E MISSOURI AVE STE 850
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2790
Practice Address - Country:US
Practice Address - Phone:203-295-4137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-16
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT59.002157133N00000X
NH0068175F00000X
AZ24-1887175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No133N00000XDietary & Nutritional Service ProvidersNutritionist