Provider Demographics
NPI:1386306231
Name:TARAWOLLIE, INNISS M
Entity type:Individual
Prefix:
First Name:INNISS
Middle Name:M
Last Name:TARAWOLLIE
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 1:5108 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3326
Mailing Address - Country:US
Mailing Address - Phone:317-760-7180
Mailing Address - Fax:
Practice Address - Street 1:5108 W 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-3326
Practice Address - Country:US
Practice Address - Phone:317-760-7180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INBC20501718335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier