Healthcare Provider Details

I. General information

NPI: 1588066088
Provider Name (Legal Business Name): ASHLEY NICOLE TARY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY NICOLE LIVERAR

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

IV. Provider business mailing address

6136 BROOKTON OAKS DR
CEDAR HILL MO
63016-2271
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5190
  • Fax: 314-353-7631
Mailing address:
  • Phone: 636-208-2832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2014018412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: