Provider Demographics
NPI:1083186589
Name:VISSERS, TAYLOR JOHN
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:JOHN
Last Name:VISSERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55246 LITTLE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:CALLAHAN
Mailing Address - State:FL
Mailing Address - Zip Code:32011-5595
Mailing Address - Country:US
Mailing Address - Phone:904-629-9678
Mailing Address - Fax:
Practice Address - Street 1:48 OSPREY VILLAGE DR
Practice Address - Street 2:
Practice Address - City:FERNANDINA
Practice Address - State:FL
Practice Address - Zip Code:32034-4955
Practice Address - Country:US
Practice Address - Phone:904-277-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28773225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant