Provider Demographics
NPI:1104860642
Name:TAYLOR, JENNIFER L (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LAVOIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 LIBERTY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-1553
Mailing Address - Country:US
Mailing Address - Phone:860-228-1119
Mailing Address - Fax:860-228-4314
Practice Address - Street 1:23 LIBERTY DR
Practice Address - Street 2:SUITE A
Practice Address - City:HEBRON
Practice Address - State:CT
Practice Address - Zip Code:06248-1553
Practice Address - Country:US
Practice Address - Phone:860-228-1119
Practice Address - Fax:860-228-4314
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002986363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004253019Medicaid
CT004253019Medicaid
CT50001445Medicare ID - Type Unspecified