Provider Demographics
NPI:1417348558
Name:MCKENNA, TARA I (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:I
Last Name:MCKENNA
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:F
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:240 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4455
Mailing Address - Country:US
Mailing Address - Phone:603-569-7574
Mailing Address - Fax:
Practice Address - Street 1:240 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4455
Practice Address - Country:US
Practice Address - Phone:603-569-7574
Practice Address - Fax:603-569-7582
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH054907-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3100493Medicaid