Provider Demographics
NPI:1417509407
Name:LIVINGSTON, TARA LYNN (FPA APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:FPA APRN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:SCOTT, PALAZZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:5901 N PROSPECT RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4358
Mailing Address - Country:US
Mailing Address - Phone:877-794-3812
Mailing Address - Fax:877-428-7891
Practice Address - Street 1:5901 N PROSPECT RD STE 202
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4358
Practice Address - Country:US
Practice Address - Phone:888-428-7890
Practice Address - Fax:877-428-7891
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002042363LP0808X
IL377001970363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health