Provider Demographics
NPI:1790088706
Name:TAYLOR, FELICIA LATRECE (RD)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:LATRECE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:FELICIA
Other - Middle Name:LATRECE
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 6363
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71136-6363
Mailing Address - Country:US
Mailing Address - Phone:318-773-4587
Mailing Address - Fax:318-671-7490
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1096133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered