Provider Demographics
NPI:1831331602
Name:ACKERLY, TARA MARIE (FNP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:ACKERLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 GERMANTOWN RD STE B05
Mailing Address - Street 2:ANTICOAGULATION CENTER
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4087
Mailing Address - Country:US
Mailing Address - Phone:203-739-7372
Mailing Address - Fax:
Practice Address - Street 1:41 GERMANTOWN RD STE B05
Practice Address - Street 2:ANTICOAGULATION CENTER
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4087
Practice Address - Country:US
Practice Address - Phone:203-739-7372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333573-1363LF0000X
CT3624363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily