MEDICARE: AUDREA LACEY LANDERS TAYLOR APRN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	30492	TN

General Provider Information

NPI Number	:	1598488249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREA LACEY LANDERS TAYLOR APRN, FNP-C

Provider Business Mailing Address
First Line	:	109 HAMPSHIRE RD
Second Line	:
City	:	SHELBYVILLE
State	:	TN
Zip	:	37160-9503
Country	:	US
Telephone Number	:	931-580-2787
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 WILSON AVE
Second Line	:
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-3357
Country	:	US
Telephone Number	:	931-580-2787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	09/19/2022

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