Basic Information
| Provider Information | |||||||||
| NPI: | 1104437631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIMTZ | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2022 KELLE DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463048708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193644004 | ||||||||
| FaxNumber: | 2193262584 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W TALMER AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH JUDSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463661335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5748965533 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2020 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 28155899A | IN | N | Nursing Service Providers | Registered Nurse | Emergency | 363L00000X | 71010414A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.