Provider Demographics
NPI:1235324062
Name:TAYLOR, CAROL PECKHAM (APRN, CNM)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:PECKHAM
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5527
Mailing Address - Country:US
Mailing Address - Phone:132-323-4500
Mailing Address - Fax:323-231-3985
Practice Address - Street 1:2707 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-5527
Practice Address - Country:US
Practice Address - Phone:132-323-4500
Practice Address - Fax:323-231-3985
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2120363LF0000X
CA670367A00000X
CA6299363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ41-1939629Medicare PIN