Provider Demographics
NPI:1427527290
Name:EDWARDS, TARA L
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3210 N STATE ROUTE 560
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-9369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:474 N YELLOW SPRINGS ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2463
Practice Address - Country:US
Practice Address - Phone:937-399-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.369924163WP0808X
OHAPRN.CNP.026062363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health