Provider Demographics
NPI:1275274532
Name:CRISTALLO, TARA MARIE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:CRISTALLO
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 1:777 BANNOCK ST # MC0108
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4597
Mailing Address - Country:US
Mailing Address - Phone:303-602-5193
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST # MC0108
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4507
Practice Address - Country:US
Practice Address - Phone:303-602-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-02
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0009615390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program