Provider Demographics
NPI:1386098861
Name:TAYLOR, NICCIA M
Entity type:Individual
Prefix:
First Name:NICCIA
Middle Name:M
Last Name:TAYLOR
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 1:28786 GLENWOOD
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-9699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2770 CARPENTER RD
Practice Address - Street 2:STE 200
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-4104
Practice Address - Country:US
Practice Address - Phone:734-971-6000
Practice Address - Fax:734-971-1026
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110124164W00000X
MI4704369544163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114014529Medicaid