Provider Demographics
NPI:1619362498
Name:CLINTON, TARYN
Entity Type:Individual
Prefix:
First Name:TARYN
Middle Name:
Last Name:CLINTON
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 1:9063 GALLOWAY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-4382
Mailing Address - Country:US
Mailing Address - Phone:904-729-5667
Mailing Address - Fax:
Practice Address - Street 1:9063 GALLOWAY DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219-4382
Practice Address - Country:US
Practice Address - Phone:904-729-5667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013901200Medicaid