Healthcare Provider Details

I. General information

NPI: 1063882538
Provider Name (Legal Business Name): TINA M TAYLOR APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SAYBROOK RD STE 206
MIDDLETOWN CT
06457-4775
US

IV. Provider business mailing address

170 FLANDERS RD
NIANTIC CT
06357-1208
US

V. Phone/Fax

Practice location:
  • Phone: 860-344-0333
  • Fax:
Mailing address:
  • Phone: 860-739-7444
  • Fax: 401-444-5527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number6365
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN01363
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: