Provider Demographics
NPI:1346759586
Name:TAYLOR, AUTUMN NICOLE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NICOLE
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 1:719 W HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2804
Mailing Address - Country:US
Mailing Address - Phone:443-883-0156
Mailing Address - Fax:
Practice Address - Street 1:1750 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6948
Practice Address - Country:US
Practice Address - Phone:443-883-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096.005126OtherIDFPR- ATHLETIC TRAINER LICENSE