Provider Demographics
NPI:1295080851
Name:VANGUNDY, TARA SUE (CFNP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:SUE
Last Name:VANGUNDY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:SUE
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:7073 CLYO RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4816
Mailing Address - Country:US
Mailing Address - Phone:937-435-5857
Mailing Address - Fax:937-912-4960
Practice Address - Street 1:1110 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:OH
Practice Address - Zip Code:45419-2911
Practice Address - Country:US
Practice Address - Phone:937-885-7163
Practice Address - Fax:937-567-0670
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA13396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0068897Medicaid
OHH148030Medicare PIN