Provider Demographics
NPI:1063069326
Name:SANDUSKY, TARA RAE (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:RAE
Last Name:SANDUSKY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:RAE
Other - Last Name:HATTABAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 TOWSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4921
Mailing Address - Country:US
Mailing Address - Phone:479-441-4000
Mailing Address - Fax:
Practice Address - Street 1:1001 TOWSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4921
Practice Address - Country:US
Practice Address - Phone:479-441-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR121897363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care