Provider Demographics
NPI:1134704059
Name:TAYLOR, MISTIE MAE
Entity Type:Individual
Prefix:
First Name:MISTIE
Middle Name:MAE
Last Name:TAYLOR
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 1:11900 AVALON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2867
Mailing Address - Country:US
Mailing Address - Phone:323-920-4959
Mailing Address - Fax:323-920-4991
Practice Address - Street 1:11900 AVALON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2867
Practice Address - Country:US
Practice Address - Phone:323-920-4959
Practice Address - Fax:323-920-4991
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist