Provider Demographics
NPI:1528323078
Name:COMARDELLE, TARA BLAKE (CRNA, MNNA, BSN)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:BLAKE
Last Name:COMARDELLE
Suffix:
Gender:F
Credentials:CRNA, MNNA, BSN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12293 OLD MILLSTONE DR
Mailing Address - Street 2:
Mailing Address - City:GEISMAR
Mailing Address - State:LA
Mailing Address - Zip Code:70734-3237
Mailing Address - Country:US
Mailing Address - Phone:407-748-1602
Mailing Address - Fax:
Practice Address - Street 1:12293 OLD MILLSTONE DR.
Practice Address - Street 2:
Practice Address - City:GEISMAR
Practice Address - State:LA
Practice Address - Zip Code:70734
Practice Address - Country:US
Practice Address - Phone:407-748-3405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LATAP002845367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered