Provider Demographics
NPI:1023120797
Name:TARDINO, LEE A (MSN ANP)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:A
Last Name:TARDINO
Suffix:
Gender:F
Credentials:MSN ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6751
Mailing Address - Country:US
Mailing Address - Phone:618-463-5905
Mailing Address - Fax:618-463-5935
Practice Address - Street 1:4 MEMORIAL DR STE 210
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-463-5905
Practice Address - Fax:618-463-5935
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO148611363LA2200X
IL209-000751363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS97920Medicare UPIN
ILK47049Medicare PIN