Healthcare Provider Details

I. General information

NPI: 1396078051
Provider Name (Legal Business Name): TARA J GENGLER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 36TH AVE
MOLINE IL
61265-7127
US

IV. Provider business mailing address

1236 E RUSHOLME ST STE 300
DAVENPORT IA
52803-2473
US

V. Phone/Fax

Practice location:
  • Phone: 309-743-6700
  • Fax: 309-764-2042
Mailing address:
  • Phone: 563-324-2992
  • Fax: 563-324-8562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209007770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: