Individual
TARAH TRACY THEVENOT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1702 E PIKES PEAK AVE, COLORADO SPRINGS, CO 80909-5717
(719) 358-7338
Mailing address
1702 E PIKES PEAK AVE, COLORADO SPRINGS, CO 80909-5717
(719) 358-7338
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
11008733
FL
363L00000X
Nurse Practitioner
Primary
C-APN.0002436-C-NP
CO
363LF0000X
Family Nurse Practitioner
11008733
FL
Other
Enumeration date
08/26/2020
Last updated
11/05/2021
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