Provider Demographics
NPI:1831526557
Name:BLACKWELDER, TARA RENE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:RENE
Last Name:BLACKWELDER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27TH SPECIAL OPERATIONS MEDICAL GROUP
Mailing Address - Street 2:224 W D. L. INGRAM AVENUE, BLDG. 1408
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103-5014
Mailing Address - Country:US
Mailing Address - Phone:575-784-2778
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVENUE, BLDG. 1408
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103-5014
Practice Address - Country:US
Practice Address - Phone:575-784-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2025-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE115187363LF0000X
AZAP8238363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily