Basic Information
| Provider Information | |||||||||
| NPI: | 1447611652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | APPLEGATE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568681 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 CIC BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST UNION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456938024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9345448989 | ||||||||
| FaxNumber: | 9375445659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2016 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.024508 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3010178 | 01 | KY | MEDICAL LICENSE | OTHER | 7100393910 | 05 | KY | MEDICAID |