Provider Demographics
NPI:1811548530
Name:ALTENTHAL, TAYLOR RAE (APRN)
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:RAE
Last Name:ALTENTHAL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:RAE
Other - Last Name:FUWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:6738 STATE HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63736-8238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PINE ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-3258
Practice Address - Country:US
Practice Address - Phone:573-472-8850
Practice Address - Fax:573-472-4050
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019025833363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily