Basic Information
| Provider Information | |||||||||
| NPI: | 1265065270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROCHLEAU | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUDSPETH, STEBURG | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 840 W US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504381023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6419251500 | ||||||||
| FaxNumber: | 6419251507 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 W US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504381023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6419251500 | ||||||||
| FaxNumber: | 6419251507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2020 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A157954 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.