Provider Demographics
NPI:1962789305
Name:MUDD, TARA UNDERWOOD (MSN, APRN, NP-C)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:UNDERWOOD
Last Name:MUDD
Suffix:
Gender:F
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:HEART RHYTHM CENTER
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-891-8400
Practice Address - Fax:502-891-8401
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007194363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201065430OtherMEDICAID - NCVA
KY7100192180Medicaid
KY50036576OtherPASSPORT - NCVA
KY000000747133OtherANTHEM - CTS/NCVA
KY131915OtherSIHO-CTS/NCVA
KY131915OtherSIHO-CTS/NCVA