Provider Demographics
NPI:1861720823
Name:DANIELS, TARA LEANNE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEANNE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:SHREWSBURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3466
Mailing Address - Country:US
Mailing Address - Phone:304-720-8816
Mailing Address - Fax:
Practice Address - Street 1:1400 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9202
Practice Address - Country:US
Practice Address - Phone:304-720-8816
Practice Address - Fax:904-494-6467
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV082506367500000X
WVAPRN66719-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9333201OtherMEDICARE GROUP
WV0207026000OtherMEDICAID GROUP