Basic Information
| Provider Information | |||||||||
| NPI: | 1265877989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | LESLIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, APRN, CCNS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LESLIE | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | JACQUELINE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DNP, RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307818 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 227 FALCON DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | MT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403539792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594975135 | ||||||||
| FaxNumber: | 8594975140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SC0200X | 3007961 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Critical Care Medicine | 364SA2100X | 3007961 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 7100257800 | 05 | KY | MEDICAID |