Healthcare Provider Details

I. General information

NPI: 1467312579
Provider Name (Legal Business Name): TIESHA TAYLOR-DUCKER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIESHA TAYLOR PMHNP-BC

II. Dates (important events)

Enumeration Date: 11/12/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

IV. Provider business mailing address

5616 COLGATE LN
MATTESON IL
60443-1509
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-1558
  • Fax:
Mailing address:
  • Phone: 217-356-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025000570
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: