Provider Demographics
NPI:1821628058
Name:SAMPLES, TAYLOR NICOLE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:SAMPLES
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 1:2974 FM 66
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75167-8415
Mailing Address - Country:US
Mailing Address - Phone:972-825-6899
Mailing Address - Fax:
Practice Address - Street 1:6301 GASTON AVE STE 750
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-6339
Practice Address - Country:US
Practice Address - Phone:214-295-5374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216081224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant