Provider Demographics
NPI:1649919481
Name:STURDAVANT, TARA LYNN (LMT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:STURDAVANT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28576 N AMETRINE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-6020
Mailing Address - Country:US
Mailing Address - Phone:616-780-9642
Mailing Address - Fax:
Practice Address - Street 1:28576 N AMETRINE WAY
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-6020
Practice Address - Country:US
Practice Address - Phone:616-780-9642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist