Provider Demographics
NPI:1316674625
Name:TAYLOR, TANNER NICHOLE (OD)
Entity type:Individual
Prefix:MRS
First Name:TANNER
Middle Name:NICHOLE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:TANNER
Other - Middle Name:NICHOLE
Other - Last Name:BARTCZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2621 S ONEIDA ST STE 104
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5793
Mailing Address - Country:US
Mailing Address - Phone:920-499-3511
Mailing Address - Fax:920-499-9215
Practice Address - Street 1:2621 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5793
Practice Address - Country:US
Practice Address - Phone:920-499-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3806-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist