MEDICARE: SHELISA RENA TAYLOR FNP-BC

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	209020023	IL
2	363LF0000X	Family Nurse Practitioner	RN160659	GA
3	363LF0000X	Family Nurse Practitioner	1-104844	AL

General Provider Information

NPI Number	:	1992277594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELISA RENA TAYLOR FNP-BC

Provider Business Mailing Address
First Line	:	1126 LEE ROAD 250
Second Line	:
City	:	SALEM
State	:	AL
Zip	:	36874-1373
Country	:	US
Telephone Number	:	706-326-0415
Fax Number	:

Provider Business Practice Location Address
First Line	:	1126 LEE ROAD 250
Second Line	:
City	:	SALEM
State	:	AL
Zip	:	36874-1373
Country	:	US
Telephone Number	:	706-326-0415
Fax Number	:

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

Provider Enumeration Date	:	12/19/2018
Last Update Date	:	10/18/2019

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