Provider Demographics
NPI:1366241713
Name:NELSON, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:NELSON
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 1:270 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5329
Mailing Address - Country:US
Mailing Address - Phone:815-276-1640
Mailing Address - Fax:
Practice Address - Street 1:910 S DONAHUE DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36832-2975
Practice Address - Country:US
Practice Address - Phone:334-442-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program