Provider Demographics
NPI:1942512157
Name:TAYLOR, KRISTIE D (NP-C)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:D
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:815 AUSTIN DR
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4513
Practice Address - Country:US
Practice Address - Phone:706-839-1333
Practice Address - Fax:706-827-5083
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101845364SP0200X
GARN101845363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
202I502541Medicare PIN