Provider Demographics
NPI:1962804294
Name:BOREN, TAMI (FNP - C)
Entity type:Individual
Prefix:
First Name:TAMI
Middle Name:
Last Name:BOREN
Suffix:
Gender:F
Credentials:FNP - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ELEVEN S STE 2B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1079
Mailing Address - Country:US
Mailing Address - Phone:618-281-7010
Mailing Address - Fax:949-543-2846
Practice Address - Street 1:1000 ELEVEN S STE 2B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1079
Practice Address - Country:US
Practice Address - Phone:618-772-1515
Practice Address - Fax:949-543-2846
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2024-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.001693363LF0000X
MO2018030480363LF0000X
IL209018123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1043774342OtherNPI