Provider Demographics
NPI:1215520929
Name:MCDANIEL, TARA BRINSON (CCMA)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:BRINSON
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5791 UNIVERSITY CLUB BLVD N UNIT 208
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-9406
Mailing Address - Country:US
Mailing Address - Phone:904-405-5181
Mailing Address - Fax:
Practice Address - Street 1:5791 UNIVERSITY CLUB BLVD N UNIT 208
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-9406
Practice Address - Country:US
Practice Address - Phone:904-405-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL236472374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL769789Medicaid