Provider Demographics
NPI:1285341826
Name:KIDD, TARA NICOLE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:NICOLE
Last Name:KIDD
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 1:4400 E HIGHWAY 20 STE 2013
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8779
Mailing Address - Country:US
Mailing Address - Phone:850-797-2598
Mailing Address - Fax:773-492-8765
Practice Address - Street 1:907 MAR WALT DR STE 2013
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6756
Practice Address - Country:US
Practice Address - Phone:817-354-5200
Practice Address - Fax:773-492-8765
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1098257363LP0808X
FLAPRN11027520363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health