Provider Demographics
NPI:1205344207
Name:BRYANT TAYLOR, TRACIE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:BRYANT TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 EDGEWOOD PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-1814
Mailing Address - Country:US
Mailing Address - Phone:859-881-0041
Mailing Address - Fax:
Practice Address - Street 1:103 EDGEWOOD PLAZA DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1814
Practice Address - Country:US
Practice Address - Phone:859-881-0041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter