Provider Demographics
NPI:1083360416
Name:KELLER MOYER, TAYLOR A
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:A
Last Name:KELLER MOYER
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 1:12430 METRIC BLVD APT 3201
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5498
Mailing Address - Country:US
Mailing Address - Phone:717-891-4313
Mailing Address - Fax:
Practice Address - Street 1:12430 METRIC BLVD APT 3201
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5498
Practice Address - Country:US
Practice Address - Phone:717-891-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85075133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered