Provider Demographics
NPI:1972754794
Name:WINGARD, TARA DANIELLE (LPN)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:DANIELLE
Last Name:WINGARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 E CACTUS RD APT 7308
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-0616
Mailing Address - Country:US
Mailing Address - Phone:870-917-7118
Mailing Address - Fax:
Practice Address - Street 1:4202 E CACTUS RD APT 7308
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-0616
Practice Address - Country:US
Practice Address - Phone:870-917-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL47240164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse