Provider Demographics
NPI:1801195466
Name:CRUMBLE, TARA L (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:CRUMBLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CHICK ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2467
Mailing Address - Country:US
Mailing Address - Phone:618-524-2176
Mailing Address - Fax:618-524-4131
Practice Address - Street 1:1204 W 10TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2433
Practice Address - Country:US
Practice Address - Phone:618-524-3572
Practice Address - Fax:618-524-3496
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010040363LF0000X
IL041407260363LF0000X
IL309010804363LF0000X
KY3006882363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000732524OtherBLUE CROSS BLUE SHIELD
KY7100159770Medicaid
KYP00960111Medicare PIN