Provider Demographics
NPI:1386915155
Name:CARDAZZONE, TARA ANN
Entity type:Individual
Prefix:MS
First Name:TARA ANN
Middle Name:
Last Name:CARDAZZONE
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 1:1458 - 73 STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228
Mailing Address - Country:US
Mailing Address - Phone:718-837-2596
Mailing Address - Fax:
Practice Address - Street 1:1458 73RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-2112
Practice Address - Country:US
Practice Address - Phone:718-837-2596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY535200111174400000X
NY447117101174400000X
NY378735091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist