Provider Demographics
NPI:1376650515
Name:TAYLOR, CHARLENE M (AUD)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:M
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13430 TARA HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2332
Mailing Address - Country:US
Mailing Address - Phone:228-863-6592
Mailing Address - Fax:228-863-1747
Practice Address - Street 1:3017 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-1833
Practice Address - Country:US
Practice Address - Phone:228-863-6592
Practice Address - Fax:228-863-1747
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA2774231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I640011OtherMEDICARE PROVIDER IDENTIFICATION NUMBER