Basic Information
| Provider Information | |||||||||
| NPI: | 1962472613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | CHOATE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE B-420 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529751 | ||||||||
| FaxNumber: | 6789905763 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE B-420 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042529751 | ||||||||
| FaxNumber: | 6789905763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 08/23/2011 | ||||||||
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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 | 363LP0200X | RN155231 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 787004190A | 05 | GA | MEDICAID | 787004190B | 05 | GA | MEDICAID | 787004190E | 05 | GA | MEDICAID |