Provider Demographics
NPI:1962922427
Name:FIVEASH, TAYLOR NICOLE (FNP-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:FIVEASH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W NORTHISDE DR, BLDG G
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:912-384-0600
Mailing Address - Fax:
Practice Address - Street 1:101 W NORTHISDE DR, BLDG G
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:912-384-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA230599363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care