Provider Demographics
NPI:1144326059
Name:STEVENS, TARA LEE (MSN, CPNP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-4527
Mailing Address - Country:US
Mailing Address - Phone:781-862-4963
Mailing Address - Fax:
Practice Address - Street 1:74 LOOMIS ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-2248
Practice Address - Country:US
Practice Address - Phone:781-674-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2265803363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics