Provider Demographics
NPI:1295484467
Name:CHAN, TAYLOR NICOLE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:CHAN
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 1:941 LAKE FRONT DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-4323
Mailing Address - Country:US
Mailing Address - Phone:916-849-7710
Mailing Address - Fax:
Practice Address - Street 1:250 SHARON PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025
Practice Address - Country:US
Practice Address - Phone:650-854-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85857183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist