Individual
AUTUMN NICOLE TAYLOR
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1750 S 4TH ST, CHAMPAIGN, IL 61820-6948
(443) 883-0156
Mailing address
719 W HARVARD ST, CHAMPAIGN, IL 61820-2804
(443) 883-0156
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
096.005126
IDFPR- ATHLETIC TRAINER LICENSE
IL
Enumeration date
09/20/2017
Last updated
10/30/2020
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