Provider Demographics
NPI:1306832274
Name:TAYLOR, TINA M (ARNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-575-8275
Mailing Address - Fax:360-575-1950
Practice Address - Street 1:945 11TH AVE STE B
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2555
Practice Address - Country:US
Practice Address - Phone:360-414-8600
Practice Address - Fax:360-636-7372
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00113328163WP0809X
WAAP30006904363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9643701Medicaid
WA8901809OtherCRIME VICTIMS
WA9643701Medicaid
Q35195Medicare UPIN
OR277944Medicaid