Provider Demographics
NPI:1508264615
Name:TAYLOR, STACIE (NP-C)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25938 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-2703
Mailing Address - Country:US
Mailing Address - Phone:216-533-0420
Mailing Address - Fax:
Practice Address - Street 1:7350 INDUSTRIAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5318
Practice Address - Country:US
Practice Address - Phone:216-732-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16509-NP363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology