Provider Demographics
NPI:1326410499
Name:EASTVOLD, TARA M (NP-C)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:EASTVOLD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:KAMMERUDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:515-241-6228
Mailing Address - Fax:515-241-5127
Practice Address - Street 1:1212 PLEASANT ST
Practice Address - Street 2:SUITE 204
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1414
Practice Address - Country:US
Practice Address - Phone:515-241-6548
Practice Address - Fax:515-241-8789
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA125292363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily