Basic Information
| Provider Information | |||||||||
| NPI: | 1619561594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 HOPEWELL AVE | ||||||||
| Address2: | |||||||||
| City: | DONNELLSON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620193121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178510992 | ||||||||
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| Practice Location | |||||||||
| Address1: | 725 SAINT FRANCIS WAY BLDG NO1 | ||||||||
| Address2: | |||||||||
| City: | LITCHFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620561780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173248798 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2021 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209022745 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.