Provider Demographics
NPI:1568924777
Name:TAYLOR, MICHELLITA ANNISE
Entity Type:Individual
Prefix:
First Name:MICHELLITA
Middle Name:ANNISE
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 1:765 EGRET BLUFF LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-7175
Mailing Address - Country:US
Mailing Address - Phone:904-571-5070
Mailing Address - Fax:
Practice Address - Street 1:531 W UNION ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-4047
Practice Address - Country:US
Practice Address - Phone:904-595-6516
Practice Address - Fax:904-406-2063
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNONEOtherNONE