Healthcare Provider Details

I. General information

NPI: 1982694303
Provider Name (Legal Business Name): LUCILLE PAULETTE TAYLOR NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 VANDENBERG DR 66TH MEDICAL GROUP / SGOF
HANSCOM AFB MA
01731-2104
US

IV. Provider business mailing address

4 COLONIAL PL
HANSCOM AFB MA
01731-2645
US

V. Phone/Fax

Practice location:
  • Phone: 781-377-8063
  • Fax:
Mailing address:
  • Phone: 781-274-8676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number161610
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: