Provider Demographics
NPI:1801620828
Name:LANZ, TARA LYNN
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:LANZ
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 1:4921 GOODWIN RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:MI
Mailing Address - Zip Code:48851-9718
Mailing Address - Country:US
Mailing Address - Phone:517-712-4701
Mailing Address - Fax:
Practice Address - Street 1:350 N CENTER ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-1212
Practice Address - Country:US
Practice Address - Phone:616-897-8473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704263184363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily