Provider Demographics
NPI:1902101405
Name:JOHNSON, TARA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:STAHLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4850 WILSON BURT RD
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NY
Mailing Address - Zip Code:14172-9654
Mailing Address - Country:US
Mailing Address - Phone:716-946-8204
Mailing Address - Fax:
Practice Address - Street 1:4850 WILSON BURT RD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NY
Practice Address - Zip Code:14172-9654
Practice Address - Country:US
Practice Address - Phone:716-946-8204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273202-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse