Provider Demographics
NPI:1508358896
Name:KRISTOCK, TARA ELIZABETH (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ELIZABETH
Last Name:KRISTOCK
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 E LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-9996
Mailing Address - Country:US
Mailing Address - Phone:248-533-0000
Mailing Address - Fax:248-385-5541
Practice Address - Street 1:71 E LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-9996
Practice Address - Country:US
Practice Address - Phone:248-533-0000
Practice Address - Fax:248-385-5541
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704300214208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704300214OtherDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BOARD OF NURSING