Healthcare Provider Details

I. General information

NPI: 1548072911
Provider Name (Legal Business Name): TARA STICKLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

4767 48TH AVE S
FARGO ND
58104-6041
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR41954
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: