Provider Demographics
NPI:1821252263
Name:STATELER, TARA JEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:JEAN
Last Name:STATELER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 4TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-1039
Mailing Address - Country:US
Mailing Address - Phone:608-328-8304
Mailing Address - Fax:608-328-1870
Practice Address - Street 1:714 4TH AVE W
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566
Practice Address - Country:US
Practice Address - Phone:608-328-8304
Practice Address - Fax:608-328-1870
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011212111N00000X
WI4433-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK53450Medicare UPIN