Healthcare Provider Details

I. General information

NPI: 1992277594
Provider Name (Legal Business Name): SHELISA RENA TAYLOR FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 LEE ROAD 250
SALEM AL
36874-1373
US

IV. Provider business mailing address

1126 LEE ROAD 250
SALEM AL
36874-1373
US

V. Phone/Fax

Practice location:
  • Phone: 706-326-0415
  • Fax:
Mailing address:
  • Phone: 706-326-0415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209020023
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN160659
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-104844
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: