Provider Demographics
NPI:1649309105
Name:SHEALY, TARA A (RN)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:A
Last Name:SHEALY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11272 CORTE PLAYA MADERA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-4137
Mailing Address - Country:US
Mailing Address - Phone:858-292-4600
Mailing Address - Fax:
Practice Address - Street 1:446 ALTA RD
Practice Address - Street 2:SUITE 6100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92158-0001
Practice Address - Country:US
Practice Address - Phone:619-671-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA392596163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent