Basic Information
Provider Information | |||||||||
NPI: | 1598935595 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONETTE | ||||||||
FirstName: | TARA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REILLY | ||||||||
OtherFirstName: | TARA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4371 VERONICA S SHOEMAKER BLVD | ||||||||
Address2: | ATTN: CREDENTIALING DEPT. | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339162216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2392748200 | ||||||||
FaxNumber: | 2392783350 | ||||||||
Practice Location | |||||||||
Address1: | 765 IMAGE WAY | ||||||||
Address2: |   | ||||||||
City: | ORANGE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 327638399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3867747411 | ||||||||
FaxNumber: | 3867747412 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2008 | ||||||||
LastUpdateDate: | 03/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9179359 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 000643700 | 05 | FL |   | MEDICAID |