MEDICARE: MISS TAELOR MCKENZIE DEIKE FNP

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	363LF0000X	Family Nurse Practitioner	1178699	TX

General Provider Information

NPI Number	:	1962226092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TAELOR MCKENZIE DEIKE FNP

Provider Business Mailing Address
First Line	:	11000 BLOSSOM BELL DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78758-4215
Country	:	US
Telephone Number	:	512-730-9455
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 N A W GRIMES BLVD STE 210
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665-2424
Country	:	US
Telephone Number	:	512-772-2929
Fax Number	:

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

Provider Enumeration Date	:	11/14/2024
Last Update Date	:	11/14/2024

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