Provider Demographics
NPI:1710704457
Name:MATNEY, TARA LUCAS (CLC, MCPD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LUCAS
Last Name:MATNEY
Suffix:
Gender:F
Credentials:CLC, MCPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 PUMP STATION RD
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28339-5500
Mailing Address - Country:US
Mailing Address - Phone:910-406-4222
Mailing Address - Fax:
Practice Address - Street 1:51 PUMP STATION RD
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:NC
Practice Address - Zip Code:28339-5500
Practice Address - Country:US
Practice Address - Phone:910-658-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC338820174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN