Healthcare Provider Details

I. General information

NPI: 1902745326
Provider Name (Legal Business Name): TASHA BANEY APRN/AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2026
Last Update Date: 03/28/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

1000 W 10TH ST
ROLLA MO
65401-2905
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-7525
  • Fax:
Mailing address:
  • Phone: 573-458-7525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2026013855
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: