Provider Demographics
NPI:1578994356
Name:TAYLOR, CHELSY LAYNE (PAC)
Entity Type:Individual
Prefix:
First Name:CHELSY
Middle Name:LAYNE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CHELSY
Other - Middle Name:LAYNE
Other - Last Name:DRYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:COUNCIL
Mailing Address - State:ID
Mailing Address - Zip Code:83612-0428
Mailing Address - Country:US
Mailing Address - Phone:208-253-4242
Mailing Address - Fax:208-253-6849
Practice Address - Street 1:205 N BERKLEY ST
Practice Address - Street 2:
Practice Address - City:COUNCIL
Practice Address - State:ID
Practice Address - Zip Code:83612-5015
Practice Address - Country:US
Practice Address - Phone:208-253-4242
Practice Address - Fax:208-253-6849
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2268363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant