MEDICARE: TAYLOR LAYNE KETTERING APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0030808	OH

General Provider Information

NPI Number	:	1255077913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR LAYNE KETTERING APRN

Provider Business Mailing Address
First Line	:	100 LILLIAN GISH BLVD SW STE 201
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44647-6500
Country	:	US
Telephone Number	:	330-809-0460
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 LILLIAN GISH BLVD SW STE 201
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44647-6500
Country	:	US
Telephone Number	:	330-809-0460
Fax Number	:	330-809-0560

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	05/06/2022

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