Provider Demographics
NPI:1104204122
Name:ROBERTSON, TARA (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:VENVERTLOH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1531 WINSOR DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-1471
Mailing Address - Country:US
Mailing Address - Phone:217-440-5089
Mailing Address - Fax:
Practice Address - Street 1:1 DOT WAY
Practice Address - Street 2:
Practice Address - City:MOUNT STERLING
Practice Address - State:IL
Practice Address - Zip Code:62353-1664
Practice Address - Country:US
Practice Address - Phone:217-773-6060
Practice Address - Fax:217-436-6762
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012568363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily