Healthcare Provider Details

I. General information

NPI: 1770991648
Provider Name (Legal Business Name): IDELLE TAYE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13737 NOEL RD STE 1600
DALLAS TX
75240-1374
US

IV. Provider business mailing address

871 LAKE CAROLYN PKWY APT 211
IRVING TX
75039-4590
US

V. Phone/Fax

Practice location:
  • Phone: 800-362-2731
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP126033
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP126033
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: