Provider Demographics
NPI:1144470121
Name:CHERRY, TARA CALICO (APN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:CALICO
Last Name:CHERRY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 KINGSBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5417
Mailing Address - Country:US
Mailing Address - Phone:901-301-1809
Mailing Address - Fax:901-946-9262
Practice Address - Street 1:360 E EH CRUMP BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38126-5310
Practice Address - Country:US
Practice Address - Phone:901-261-2025
Practice Address - Fax:901-946-9262
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10904363LP0808X
TN13580363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty