Healthcare Provider Details

I. General information

NPI: 1447478342
Provider Name (Legal Business Name): KAKECHA TIWANA TAYLOR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 HIGHWAY 51 S STE A
HERNANDO MS
38632-2725
US

IV. Provider business mailing address

5504 DEER TRAIL CV
SOUTHAVEN MS
38672-9307
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-9814
  • Fax:
Mailing address:
  • Phone: 662-832-1878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number29839
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904746
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: