Provider Demographics
NPI:1487103263
Name:ERICKSON, TARA (RN)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4912 E MAYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-5928
Mailing Address - Country:US
Mailing Address - Phone:605-254-3722
Mailing Address - Fax:
Practice Address - Street 1:2201 W 95TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-6441
Practice Address - Country:US
Practice Address - Phone:605-743-2567
Practice Address - Fax:605-275-9140
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR039986163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse