Provider Demographics
NPI:1174010995
Name:DEBERRY, TAYLOR RAE (LPN)
Entity type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:RAE
Last Name:DEBERRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:TAYLOR
Other - Middle Name:RAE
Other - Last Name:ELLSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:925 HIGHWAY V V
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857
Mailing Address - Country:US
Mailing Address - Phone:573-888-5925
Mailing Address - Fax:
Practice Address - Street 1:925 HIGHWAY V V
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857
Practice Address - Country:US
Practice Address - Phone:573-888-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027883164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse