Provider Demographics
NPI:1093279804
Name:PATRICK TAYLOR, TARA (MS)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PATRICK TAYLOR
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2392 EDGEWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-1725
Mailing Address - Country:US
Mailing Address - Phone:267-219-8654
Mailing Address - Fax:904-781-8685
Practice Address - Street 1:2392 NORTH EDGEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254
Practice Address - Country:US
Practice Address - Phone:267-219-8654
Practice Address - Fax:904-781-8685
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ99988OtherMEDICAID/HEALTH CARE/
NJ999999OtherINSURANCE
NJ99999999Medicaid