Provider Demographics
NPI:1871275974
Name:KING, TARA SUE (ACNP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:SUE
Last Name:KING
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 MARIBELLA CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7749
Mailing Address - Country:US
Mailing Address - Phone:484-788-3387
Mailing Address - Fax:
Practice Address - Street 1:433 MARIBELLA CT
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7749
Practice Address - Country:US
Practice Address - Phone:484-788-3387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026947363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner