Provider Demographics
NPI:1649991126
Name:SIMON, TARA LEIGH (DNP, CRNA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LEIGH
Last Name:SIMON
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2534
Mailing Address - Country:US
Mailing Address - Phone:231-881-2361
Mailing Address - Fax:
Practice Address - Street 1:1028 EMMET ST APT B
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2930
Practice Address - Country:US
Practice Address - Phone:231-881-2361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704326900367500000X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine