Healthcare Provider Details

I. General information

NPI: 1023352853
Provider Name (Legal Business Name): DUSTIN A. TAYLOR PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

1000 E 24TH ST STE 2E
KANSAS CITY MO
64108-2776
US

V. Phone/Fax

Practice location:
  • Phone: 224-610-3744
  • Fax:
Mailing address:
  • Phone: 816-404-5850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number53-76164-082
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2019038872
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: