Healthcare Provider Details

I. General information

NPI: 1255072450
Provider Name (Legal Business Name): TAYLOR ASHLEY REVERE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE
ATLANTA GA
30308-2212
US

IV. Provider business mailing address

ONE GUSTAVE LEVY PLACE, BOX 1149
NEW YORK NY
10029
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-4411
  • Fax:
Mailing address:
  • Phone: 770-344-7167
  • 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 State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number113721
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: