Healthcare Provider Details

I. General information

NPI: 1184285371
Provider Name (Legal Business Name): TAYLOR MARIE BOURELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 SILLECT AVE STE 100
BAKERSFIELD CA
93308-6372
US

IV. Provider business mailing address

2901 SILLECT AVE
BAKERSFIELD CA
93308-6371
US

V. Phone/Fax

Practice location:
  • Phone: 661-323-8384
  • Fax:
Mailing address:
  • Phone: 660-323-8384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA56946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: