Provider Demographics
NPI:1043926710
Name:STATEN, TAKARA MONIQUE
Entity Type:Individual
Prefix:
First Name:TAKARA
Middle Name:MONIQUE
Last Name:STATEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 SAN FELIPE BLVD APT 504
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-7694
Mailing Address - Country:US
Mailing Address - Phone:701-495-3540
Mailing Address - Fax:
Practice Address - Street 1:7800 SAN FELIPE BLVD APT 504
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-7694
Practice Address - Country:US
Practice Address - Phone:701-495-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA0061032783376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376K00000XMedicaid