Provider Demographics
NPI:1679083760
Name:TAYLOR, TANIYA KELLEASE
Entity type:Individual
Prefix:MS
First Name:TANIYA
Middle Name:KELLEASE
Last Name: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 1:1138 E AVENUE J12
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4299
Mailing Address - Country:US
Mailing Address - Phone:661-435-3284
Mailing Address - Fax:
Practice Address - Street 1:43909 30TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-5843
Practice Address - Country:US
Practice Address - Phone:661-952-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid