Provider Demographics
NPI:1316672975
Name:LISKE, TARA (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LISKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:866-234-8534
Mailing Address - Fax:
Practice Address - Street 1:109 W WALL ST
Practice Address - Street 2:
Practice Address - City:FROSTPROOF
Practice Address - State:FL
Practice Address - Zip Code:33843-2043
Practice Address - Country:US
Practice Address - Phone:866-234-8534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11020765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115868500Medicaid