Provider Demographics
NPI:1033709662
Name:WHITAKER, TAIESHA
Entity Type:Individual
Prefix:
First Name:TAIESHA
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9305 SPIDER LILY LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-6011
Mailing Address - Country:US
Mailing Address - Phone:904-524-7385
Mailing Address - Fax:
Practice Address - Street 1:9305 SPIDER LILY LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219-6011
Practice Address - Country:US
Practice Address - Phone:904-524-7385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL236509253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107236200Medicaid