=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477256345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA RENE CHRISTY RN, BSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2023
-----------------------------------------------------
Last Update Date | 03/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4101 S 4TH ST
-----------------------------------------------------
City | LEAVENWORTH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66048-5014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-682-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3404 N 128TH ST
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66109-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-306-3356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 104891
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------