Healthcare Provider Details

I. General information

NPI: 1013667831
Provider Name (Legal Business Name): LASHAWNDA KATINA TAYLOR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 06/10/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MYRTLE BOULEVARD
GRACEWOOD GA
30812
US

IV. Provider business mailing address

PO BOX 2510
AUGUSTA GA
30809-2510
US

V. Phone/Fax

Practice location:
  • Phone: 706-790-2011
  • Fax:
Mailing address:
  • Phone: 706-922-8251
  • Fax: 706-922-6695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN152884
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: