Provider Demographics
NPI:1790524726
Name:TAYAR LICURGO, SORAYA
Entity type:Individual
Prefix:
First Name:SORAYA
Middle Name:
Last Name:TAYAR LICURGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SORAYA
Other - Middle Name:
Other - Last Name:SALGADO TAYAR LICURGO DE AZEVEDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15024 CHAPTER WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-1764
Mailing Address - Country:US
Mailing Address - Phone:901-389-0967
Mailing Address - Fax:
Practice Address - Street 1:15024 CHAPTER WAY
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-1764
Practice Address - Country:US
Practice Address - Phone:901-389-0967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN