1104860642 NPI number — JENNIFER L TAYLOR A.P.R.N.

Table of content: JENNIFER L TAYLOR A.P.R.N. (NPI 1104860642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104860642 NPI number — JENNIFER L TAYLOR A.P.R.N.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.P.R.N.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAVOIE
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104860642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 LIBERTY DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
HEBRON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06248-1553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-228-1119
Provider Business Mailing Address Fax Number:
860-228-4314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 LIBERTY DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HEBRON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06248-1553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-228-1119
Provider Business Practice Location Address Fax Number:
860-228-4314
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  002986 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 002986 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004253019 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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