Provider Demographics
NPI:1568280451
Name:LEEDHAM, TARA (NP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LEEDHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:SWIGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 N TRIUMPH BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6475
Mailing Address - Country:US
Mailing Address - Phone:801-821-2613
Mailing Address - Fax:
Practice Address - Street 1:20950 N TATUM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4255
Practice Address - Country:US
Practice Address - Phone:480-626-7584
Practice Address - Fax:480-210-0230
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ314700363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health