Provider Demographics
NPI:1932598323
Name:WILLIAMS, TARA LYNN (FNP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4285 W STATE ROUTE 571
Mailing Address - Street 2:
Mailing Address - City:WEST MILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45383-9786
Mailing Address - Country:US
Mailing Address - Phone:937-600-2339
Mailing Address - Fax:
Practice Address - Street 1:4285 W STATE ROUTE 571
Practice Address - Street 2:
Practice Address - City:WEST MILTON
Practice Address - State:OH
Practice Address - Zip Code:45383-9786
Practice Address - Country:US
Practice Address - Phone:937-305-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.16981363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0118676Medicaid
OH0118676Medicaid