Healthcare Provider Details

I. General information

NPI: 1619211992
Provider Name (Legal Business Name): DEONTRANESE TREVA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 MAIN ST STE D
MONTICELLO MS
39654-3702
US

IV. Provider business mailing address

314 MAIN ST STE D
MONTICELLO MS
39654-3702
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-4304
  • Fax:
Mailing address:
  • Phone: 601-587-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR865884
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR865884
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: