Provider Demographics
NPI:1164102646
Name:SAMBUCCI, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:SAMBUCCI
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 1:1409 PADDINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-9613
Mailing Address - Country:US
Mailing Address - Phone:630-740-9790
Mailing Address - Fax:
Practice Address - Street 1:1409 PADDINGTON CIR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-9613
Practice Address - Country:US
Practice Address - Phone:630-740-9790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11312133V00000X
KS2897133V00000X
IL86154329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered