Healthcare Provider Details

I. General information

NPI: 1558002170
Provider Name (Legal Business Name): MS. TAJUANA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date: 01/20/2023
Reactivation Date: 02/20/2023

III. Provider practice location address

129 LAURA AVE
DAYTON OH
45405-3103
US

IV. Provider business mailing address

129 LAURA AVE
DAYTON OH
45405-3103
US

V. Phone/Fax

Practice location:
  • Phone: 937-977-0605
  • Fax:
Mailing address:
  • Phone: 937-977-0605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: