Provider Demographics
NPI:1679965438
Name:PANNULLO, TARRA LYNN (MA, NCC)
Entity type:Individual
Prefix:
First Name:TARRA
Middle Name:LYNN
Last Name:PANNULLO
Suffix:
Gender:F
Credentials:MA, NCC
Other - Prefix:
Other - First Name:TARRA
Other - Middle Name:
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-5646
Mailing Address - Country:US
Mailing Address - Phone:407-875-3700
Mailing Address - Fax:407-659-0411
Practice Address - Street 1:9000 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-8802
Practice Address - Country:US
Practice Address - Phone:954-440-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FLIMH21446101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator