MEDICARE: TRINA TAYLOR LPN

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	164W00000X	Licensed Practical Nurse	PN107084	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2575511	OTHER	OH	INDEPENDENT PROVIDER #

General Provider Information

NPI Number	:	1386868412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRINA TAYLOR LPN

Provider Business Mailing Address
First Line	:	10712 MILLERS FORK RD
Second Line	:
City	:	LEWISBURG
State	:	OH
Zip	:	45338-9720
Country	:	US
Telephone Number	:	937-489-3911
Fax Number	:

Provider Business Practice Location Address
First Line	:	10712 MILLERS FORK RD
Second Line	:
City	:	LEWISBURG
State	:	OH
Zip	:	45338-9720
Country	:	US
Telephone Number	:	937-489-3911
Fax Number	:

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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