Healthcare Provider Details

I. General information

NPI: 1437720364
Provider Name (Legal Business Name): TAYLOR GLAZE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 GA HIGHWAY 96 STE D3-D5
KATHLEEN GA
31047-2111
US

IV. Provider business mailing address

1114 GA HIGHWAY 96 STE D3-D5
KATHLEEN GA
31047-2111
US

V. Phone/Fax

Practice location:
  • Phone: 478-910-1090
  • Fax:
Mailing address:
  • Phone: 478-910-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberRN239691
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN239691
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: