Provider Demographics
NPI:1629649728
Name:DEARTH, TAYLOR LYNN
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LYNN
Last Name:DEARTH
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 1:39116 PRINCETON CIR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-1777
Mailing Address - Country:US
Mailing Address - Phone:330-559-4238
Mailing Address - Fax:
Practice Address - Street 1:602 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-1499
Practice Address - Country:US
Practice Address - Phone:330-559-4238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH8104133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH02122244Medicaid