Basic Information
| Provider Information | |||||||||
| NPI: | 1417443433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAINIERI | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | LAINE | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 396 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124014626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453313131 | ||||||||
| FaxNumber: | 8458027362 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 MARYS AVE | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124015848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453382500 | ||||||||
| FaxNumber: | 8458027362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2018 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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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 | 363LF0000X | 343244 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 05351693 | 05 | NY | MEDICAID |