MEDICARE: TAYLOR RAE PARK NP

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	363LP2300X	Primary Care Nurse Practitioner	2023037394	MO
2	163W00000X	Registered Nurse	2016023237	MO
3	363L00000X	Nurse Practitioner	2023037394	MO
4	363LF0000X	Family Nurse Practitioner	209029415	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	209029415	OTHER	IL	NP LICENSE
2	16161910	OTHER		CAQH ID

General Provider Information

NPI Number	:	1780454389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR RAE PARK NP

Provider Business Mailing Address
First Line	:	PO BOX 959354
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-9354
Country	:	US
Telephone Number	:	314-953-8271
Fax Number	:	314-953-8272

Provider Business Practice Location Address
First Line	:	1225 GRAHAM RD STE C-1340
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63031-8019
Country	:	US
Telephone Number	:	314-953-8271
Fax Number	:

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

Provider Enumeration Date	:	01/04/2024
Last Update Date	:	09/17/2025

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