Provider Demographics
NPI:1104004134
Name:WEIRICH, TARA LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:WEIRICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16552 STATE HIGHWAY 109
Mailing Address - Street 2:
Mailing Address - City:DOW
Mailing Address - State:IL
Mailing Address - Zip Code:62022-3067
Mailing Address - Country:US
Mailing Address - Phone:618-567-3706
Mailing Address - Fax:
Practice Address - Street 1:12990 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-1860
Practice Address - Country:US
Practice Address - Phone:314-367-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006957367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered