Provider Demographics
NPI:1902539463
Name:KRISTIANSEN, TARA (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KRISTIANSEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 E PLANK RD
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8757
Mailing Address - Country:US
Mailing Address - Phone:502-551-7002
Mailing Address - Fax:
Practice Address - Street 1:165 E PLANK RD
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-8757
Practice Address - Country:US
Practice Address - Phone:844-599-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-02
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.025406363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily