Healthcare Provider Details

I. General information

NPI: 1154811255
Provider Name (Legal Business Name): MISS KAITLIN LOU TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E MAIN ST
SIDNEY IL
61877-7634
US

IV. Provider business mailing address

312 E MAIN ST
SIDNEY IL
61877-7634
US

V. Phone/Fax

Practice location:
  • Phone: 217-621-4284
  • Fax:
Mailing address:
  • Phone: 217-621-4284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: