Provider Demographics
NPI:1922529080
Name:TAYLOR, BRADLEY SHANE (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SHANE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 VILLAGE SQUARE DR STE C
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7448
Mailing Address - Country:US
Mailing Address - Phone:270-228-0118
Mailing Address - Fax:270-228-0120
Practice Address - Street 1:4645 VILLAGE SQUARE DR STE C
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7448
Practice Address - Country:US
Practice Address - Phone:270-228-0118
Practice Address - Fax:270-228-0120
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016137363LF0000X
KY3011419363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily