Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 2087 | NC |
NPI | 1164950903 |
---|---|
Provider Name | Kelley Taylor |
First Address | Mocksville, NC 27028-2415 |
Second Address | Mocksville, NC 27028-2415 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2017 |
Last Update Date | 24/05/2017 |