TAYLOR MARIE MANIVANNAN Physician Assistant License verification

Business Entity

ACTIVE

License Type

Physician Assistant

Description

PHYSICIAN ASSISTANT CONTROLLED SUBSTANCE

License Number

38*****64

License Status

ACTIVE

Business

First Name

TAYLOR

Middle

MARIE

Last Name

MANIVANNAN

Business Name

TAYLOR MARIE MANIVANNAN

Original Issue Date

10/19/2015

Effective Date

12/29/2025

Expiration Date

03/01/2028

City

SPRINGFIELD

State

Zip

62704

County

SANGAMON

Delegated Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

12/29/2025