Provider Demographics
NPI:1861861635
Name:DOUGLAS, TAYLOE
Entity Type:Individual
Prefix:
First Name:TAYLOE
Middle Name:
Last Name:DOUGLAS
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 1:15415 KENNY DR
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77377-8630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15451 KENNY DRIVE
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77377
Practice Address - Country:US
Practice Address - Phone:817-915-1665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35077658390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program