Provider Demographics
NPI:1902981913
Name:TAYLOR, VICKI LYNN
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:LYNN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:VICKI
Other - Middle Name:LYNN
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:11803 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-258-5522
Mailing Address - Fax:414-258-1337
Practice Address - Street 1:11803 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-258-5522
Practice Address - Fax:414-258-1337
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21533208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30016800Medicaid
AT1151175OtherBND#
WI30016800Medicaid
E32707Medicare UPIN