Provider Demographics
NPI:1386962140
Name:BRANNEN, TARA LEIGH (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LEIGH
Last Name:BRANNEN
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 1:445 S FIGUEROA ST FL 31
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90071-1602
Mailing Address - Country:US
Mailing Address - Phone:888-731-8994
Mailing Address - Fax:833-775-1861
Practice Address - Street 1:139 CENTRE ST PH 120
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4559
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9218740363LF0000X
FL9218740363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003821900Medicaid
FLY05CWOtherBCBS
FL003821900Medicaid