Provider Demographics
NPI:1609530807
Name:TAYLOR, TELISA (NP)
Entity Type:Individual
Prefix:MS
First Name:TELISA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 ST PATRICK DRIVE STE 104, #114
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603
Mailing Address - Country:US
Mailing Address - Phone:202-528-7595
Mailing Address - Fax:
Practice Address - Street 1:199 OAK ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359-1912
Practice Address - Country:US
Practice Address - Phone:202-528-7595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR180238363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health