Healthcare Provider Details

I. General information

NPI: 1346809191
Provider Name (Legal Business Name): MARISSA LORRAINE TAYLOR AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 WASHINGTON AVE S
EDEN PRAIRIE MN
55344-3405
US

IV. Provider business mailing address

116 PENLEY CT
FORT KNOX KY
40121-6003
US

V. Phone/Fax

Practice location:
  • Phone: 952-947-4700
  • Fax:
Mailing address:
  • Phone: 502-756-1374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number13598
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: