Provider Demographics
NPI:1124294764
Name:ALBERT, TARA MARLAINE (CPNP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARLAINE
Last Name:ALBERT
Suffix:
Gender:F
Credentials:CPNP
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Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 537A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6990
Mailing Address - Fax:314-251-6998
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 537A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6990
Practice Address - Fax:314-251-6998
Is Sole Proprietor?:No
Enumeration Date:2008-05-04
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO151691363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124294764Medicaid
102620003Medicare UPIN