Healthcare Provider Details

I. General information

NPI: 1205344207
Provider Name (Legal Business Name): TRACIE BRYANT TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 EDGEWOOD PLAZA DR
NICHOLASVILLE KY
40356-1814
US

IV. Provider business mailing address

103 EDGEWOOD PLAZA DR
NICHOLASVILLE KY
40356-1814
US

V. Phone/Fax

Practice location:
  • Phone: 859-881-0041
  • Fax:
Mailing address:
  • Phone: 859-881-0041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: