Provider Demographics
NPI:1740640762
Name:WILSON, TARA STARR (LPN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:STARR
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 FERGUSON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2430
Mailing Address - Country:US
Mailing Address - Phone:513-815-2895
Mailing Address - Fax:
Practice Address - Street 1:3011 FERGUSON RD
Practice Address - Street 2:2
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2430
Practice Address - Country:US
Practice Address - Phone:513-815-2895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH157760164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse