Provider Demographics
NPI:1679738116
Name:PEZZUTO, TARA A (APN)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:A
Last Name:PEZZUTO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:AYN
Other - Last Name:MELCHIOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1600 ROCKLAND RD
Practice Address - Street 2:ALFRED I. DUPONT HOSPITAL FOR CHILDREN
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4000
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEAPN0001488363L00000X
DEL10026764363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner