Provider Demographics
NPI:1427700327
Name:LEA, TARA ADRIENNE (LVN, FNLP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ADRIENNE
Last Name:LEA
Suffix:
Gender:F
Credentials:LVN, FNLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34161 YUCAIPA BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6109
Mailing Address - Country:US
Mailing Address - Phone:909-797-1277
Mailing Address - Fax:
Practice Address - Street 1:34161 YUCAIPA BLVD STE F
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-6109
Practice Address - Country:US
Practice Address - Phone:909-797-1277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date: