Provider Demographics
NPI:1306461298
Name:TAYLOR, MICHAEL ROBERT (LPN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 LENA ST
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-4208
Mailing Address - Country:US
Mailing Address - Phone:208-756-8515
Mailing Address - Fax:208-756-8385
Practice Address - Street 1:705 LENA ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4208
Practice Address - Country:US
Practice Address - Phone:208-756-8515
Practice Address - Fax:208-756-8385
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPN-14621164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse