Healthcare Provider Details

I. General information

NPI: 1124294764
Provider Name (Legal Business Name): TARA MARLAINE ALBERT CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2008
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 537A
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD SUITE 537A
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6990
  • Fax: 314-251-6998
Mailing address:
  • Phone: 314-251-6990
  • Fax: 314-251-6998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number151691
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: