Healthcare Provider Details

I. General information

NPI: 1609853415
Provider Name (Legal Business Name): TARA L SCHLATTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PARK NICOLLET CLINIC SENIOR SERVICES 3850 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-5041
  • Fax:
Mailing address:
  • Phone: 952-993-7169
  • Fax: 952-993-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberR 141410-3
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number15488-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: