Healthcare Provider Details

I. General information

NPI: 1629516455
Provider Name (Legal Business Name): TARA NICHOLE GALLOWAY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-2000
  • Fax:
Mailing address:
  • Phone: 314-362-9123
  • Fax: 314-747-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017001488
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: