Provider Demographics
NPI:1114150216
Name:TAYLOR, THERESE MAE' (LPN)
Entity Type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:MAE'
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10358 N 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-6782
Mailing Address - Country:US
Mailing Address - Phone:623-486-2277
Mailing Address - Fax:
Practice Address - Street 1:10358 N 78TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-6782
Practice Address - Country:US
Practice Address - Phone:623-486-2277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP045474164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse