Healthcare Provider Details

I. General information

NPI: 1679420202
Provider Name (Legal Business Name): TAYLOR DIANNE DUNLEAVY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13841 JASMINE CT
ROGERS MN
55374-8895
US

IV. Provider business mailing address

13841 JASMINE CT
ROGERS MN
55374-8895
US

V. Phone/Fax

Practice location:
  • Phone: 763-567-1562
  • Fax:
Mailing address:
  • Phone: 763-567-1562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number390200000X
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: