Healthcare Provider Details

I. General information

NPI: 1164194569
Provider Name (Legal Business Name): LENA CLAIR TAYLOR APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10518 EGRET HAVEN LN
RIVERVIEW FL
33578-3358
US

IV. Provider business mailing address

10518 EGRET HAVEN LN
RIVERVIEW FL
33578-3358
US

V. Phone/Fax

Practice location:
  • Phone: 850-390-5206
  • Fax:
Mailing address:
  • Phone: 850-390-5206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11015492
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11015492
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11015492
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: