Healthcare Provider Details

I. General information

NPI: 1376892083
Provider Name (Legal Business Name): MOLLY J TAYLOR ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 HUNTINGTON RD
RICHMOND VT
05477-9708
US

IV. Provider business mailing address

85 N UNION ST
BURLINGTON VT
05401-3963
US

V. Phone/Fax

Practice location:
  • Phone: 802-434-8495
  • Fax:
Mailing address:
  • Phone: 802-770-9485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104.0088590
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: