Provider Demographics
NPI:1316714736
Name:PATRICK, TARA LEANNE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LEANNE
Last Name:PATRICK
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:PO BOX 6098
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-6098
Mailing Address - Country:US
Mailing Address - Phone:270-765-9478
Mailing Address - Fax:
Practice Address - Street 1:415 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1162
Practice Address - Country:US
Practice Address - Phone:270-765-9478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty