Basic Information
| Provider Information | |||||||||
| NPI: | 1285608703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | SHANNON | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.N.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26005 RIDGE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DAMASCUS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208721892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014142300 | ||||||||
| FaxNumber: | 3014142306 | ||||||||
| Practice Location | |||||||||
| Address1: | 26005 RIDGE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DAMASCUS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208721892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014142300 | ||||||||
| FaxNumber: | 3014142306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 02/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 0024165986 | VA | Y | Other Service Providers | Midwife | 163W00000X | 0001146963 | VA | N | Nursing Service Providers | Registered Nurse | 367A00000X | AC00911 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 010130484 | 05 | VA | MEDICAID | 7002042 | 05 | NC | MEDICAID | 175079 | 01 | VA | ANTHEM | OTHER | 010061873 | 05 | VA | MEDICAID | 2125746 | 01 | VA | UHC/MAMSI | OTHER | 75928N | 01 | VA | SENTARA/OPTIMA | OTHER |