Provider Demographics
NPI:1720268428
Name:TAYLOR, KATHLEEN M (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 TEXAS ST
Mailing Address - Street 2:SUITE #200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3524
Mailing Address - Country:US
Mailing Address - Phone:888-447-2450
Mailing Address - Fax:
Practice Address - Street 1:3300 S FM 1788
Practice Address - Street 2:BEHAV CTR OF AMER PERMIAN BASIN
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-2601
Practice Address - Country:US
Practice Address - Phone:432-591-5915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX828712363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX274217YPZ2Medicare PIN