=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487124418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CELESTE NICOLE TAYLOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2018
-----------------------------------------------------
Last Update Date | 12/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 HIGHLAND XING
-----------------------------------------------------
City | EAST ELLIJAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30540-6052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-276-1180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 314 NEW POINT LN
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-3593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-314-8399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 13444-040
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH022837
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------