Provider Demographics
NPI:1801452693
Name:PEMBERTON, TARA SHARIE (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:SHARIE
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3605 NORTHGATE CT STE 110
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6400
Practice Address - Country:US
Practice Address - Phone:812-949-5749
Practice Address - Fax:812-949-5794
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2020-10-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY3013178363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily