Healthcare Provider Details

I. General information

NPI: 1568924777
Provider Name (Legal Business Name): MICHELLITA ANNISE TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 W UNION ST
JACKSONVILLE FL
32202-4047
US

IV. Provider business mailing address

765 EGRET BLUFF LN
JACKSONVILLE FL
32211-7175
US

V. Phone/Fax

Practice location:
  • Phone: 904-595-6516
  • Fax: 904-406-2063
Mailing address:
  • Phone: 904-571-5070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA16931
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: