Provider Demographics
NPI:1023652898
Name:HANNON, TAYLOR NICOLE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:HANNON
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 1:5212 WILD LIFE CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-0406
Mailing Address - Country:US
Mailing Address - Phone:909-816-5208
Mailing Address - Fax:
Practice Address - Street 1:1020 S ARROYO PKWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3911
Practice Address - Country:US
Practice Address - Phone:626-403-2794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41404167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician