Provider Demographics
NPI:1841661709
Name:CHERNECKE, TARA REED (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:REED
Last Name:CHERNECKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:REED
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:9702 STONESTREET RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-6809
Practice Address - Country:US
Practice Address - Phone:502-588-0610
Practice Address - Fax:502-588-0611
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201330940Medicaid
KY7100375710Medicaid
KY3009407OtherSTATE LICENSE