Provider Demographics
NPI:1538593306
Name:ROBINSON TAYLOR, MIRANDA (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:ROBINSON TAYLOR
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6524
Mailing Address - Country:US
Mailing Address - Phone:229-529-1134
Mailing Address - Fax:229-529-1134
Practice Address - Street 1:1940 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6524
Practice Address - Country:US
Practice Address - Phone:229-529-1134
Practice Address - Fax:229-529-1134
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO0754741744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management