Provider Demographics
NPI:1952973182
Name:QUINTANA, TARA J
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:QUINTANA
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 1:2815 E 3RD ST # 1052
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5434
Mailing Address - Country:US
Mailing Address - Phone:930-333-1435
Mailing Address - Fax:
Practice Address - Street 1:5275 W COWDEN RD # 1052
Practice Address - Street 2:
Practice Address - City:ELLETTSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47429-9325
Practice Address - Country:US
Practice Address - Phone:930-333-1435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28202480A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner