Healthcare Provider Details

I. General information

NPI: 1225665946
Provider Name (Legal Business Name): LARRY LEE TAYLOR JR. NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 TIFT AVE N STE D
TIFTON GA
31794-3579
US

IV. Provider business mailing address

737 DONNA AVE
ASHBURN GA
31714-3445
US

V. Phone/Fax

Practice location:
  • Phone: 555-422-9382
  • Fax:
Mailing address:
  • Phone: 229-457-9598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN214375
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: