Provider Demographics
NPI:1124864673
Name:MERSINO, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MERSINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 WEDGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-2581
Mailing Address - Country:US
Mailing Address - Phone:706-588-8602
Mailing Address - Fax:
Practice Address - Street 1:122 N 20TH ST BLDG 24
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5442
Practice Address - Country:US
Practice Address - Phone:334-745-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-176811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily