Provider Demographics
NPI:1780454389
Name:PARK, TAYLOR RAE (NP)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RAE
Last Name:PARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 959354
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-9354
Mailing Address - Country:US
Mailing Address - Phone:314-953-8271
Mailing Address - Fax:314-953-8272
Practice Address - Street 1:903 S STATE ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2344
Practice Address - Country:US
Practice Address - Phone:618-498-2273
Practice Address - Fax:618-639-8100
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2016023237163W00000X
IL209029415363LF0000X
MO2023037394363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209029415OtherNP LICENSE
16161910OtherCAQH ID