Healthcare Provider Details

I. General information

NPI: 1295441681
Provider Name (Legal Business Name): TARA KATHRYN SIEBENALLER MS, APRN, AGCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number209.030168
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number041566133
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number2023044985
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: