Healthcare Provider Details

I. General information

NPI: 1316573173
Provider Name (Legal Business Name): LATARA TAYLOR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14518 CHERRY LAKE DR W
JACKSONVILLE FL
32258-5140
US

IV. Provider business mailing address

14518 CHERRY LAKE DR W
JACKSONVILLE FL
32258-5140
US

V. Phone/Fax

Practice location:
  • Phone: 904-629-9164
  • Fax:
Mailing address:
  • Phone: 904-200-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCAPN0003970
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1081153
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11007178
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: