Provider Demographics
NPI:1669826657
Name:TAYLOR, HEREDESHEE LATRICE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:HEREDESHEE
Middle Name:LATRICE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:HEREDESHEE
Other - Middle Name:LATRICE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3201 HOLDEN CIR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4435
Mailing Address - Country:US
Mailing Address - Phone:773-531-9794
Mailing Address - Fax:
Practice Address - Street 1:3201 HOLDEN CIR
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443
Practice Address - Country:US
Practice Address - Phone:773-531-9794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-16
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily