Healthcare Provider Details

I. General information

NPI: 1093277899
Provider Name (Legal Business Name): ALTELISHA LANAE TAYLOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 LEE ST SW FL 2
ATLANTA GA
30310-1408
US

IV. Provider business mailing address

455 LEE ST SW FL 2
ATLANTA GA
30310-1408
US

V. Phone/Fax

Practice location:
  • Phone: 404-756-1241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA178138
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number11034
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: