Provider Demographics
NPI:1811435191
Name:MASTIN, TAYLOR
Entity type:Individual
Prefix:MISS
First Name:TAYLOR
Middle Name:
Last Name:MASTIN
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 1:153 NEW TOWNE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4577
Mailing Address - Country:US
Mailing Address - Phone:315-264-7585
Mailing Address - Fax:
Practice Address - Street 1:153 NEW TOWNE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4577
Practice Address - Country:US
Practice Address - Phone:315-264-7585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program