Provider Demographics
NPI:1891183778
Name:BOBO, TARA SUZANNE
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:SUZANNE
Last Name:BOBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:43107-1033
Mailing Address - Country:US
Mailing Address - Phone:740-503-7603
Mailing Address - Fax:
Practice Address - Street 1:301 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:OH
Practice Address - Zip Code:43107-1033
Practice Address - Country:US
Practice Address - Phone:740-503-7603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-31
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 158321-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse