1700155793 NPI number — MS. KRISTIE MARIE TAGGART PNP

Table of content: MS. KRISTIE MARIE TAGGART PNP (NPI 1700155793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700155793 NPI number — MS. KRISTIE MARIE TAGGART PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAGGART
Provider First Name:
KRISTIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700155793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60352
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63160-0352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-362-1408
Provider Business Mailing Address Fax Number:
314-454-2523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13001 N OUTER 40 RD
Provider Second Line Business Practice Location Address:
DIV NEUROLOGY PEDIATRICS, STE 1A
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63017-5941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-362-1408
Provider Business Practice Location Address Fax Number:
314-454-2523
Provider Enumeration Date:
12/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0222X , with the licence number:  2020038104 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 420096100 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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