Basic Information
| Provider Information | |||||||||
| NPI: | 1952728651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742616 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702198420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12192 AUGUSTA RD | ||||||||
| Address2: | |||||||||
| City: | LAVONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305531209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063561072 | ||||||||
| FaxNumber: | 7063561457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2014 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN.18738 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | RN191398 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.