Provider Demographics
NPI:1255989919
Name:REISMANN, TAYLOR LINDSEY (PA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LINDSEY
Last Name:REISMANN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4909 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4689
Mailing Address - Country:US
Mailing Address - Phone:309-674-7546
Mailing Address - Fax:309-691-9286
Practice Address - Street 1:1800 E 54TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2852
Practice Address - Country:US
Practice Address - Phone:563-344-7546
Practice Address - Fax:309-344-1373
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008296363A00000X
IA108139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty