Healthcare Provider Details

I. General information

NPI: 1740811371
Provider Name (Legal Business Name): TAYLOR NICOLE MUTCHLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2020
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 MARKET SQUARE DR
PRINCE FREDERICK MD
20678-3173
US

IV. Provider business mailing address

570 CARLA DR
HUNTINGTOWN MD
20639-9648
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-5313
  • Fax:
Mailing address:
  • Phone: 301-536-6451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28781
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPI02082
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: