Provider Demographics
NPI:1962011395
Name:DEACON, TAYLOR (RDN, LDN)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:DEACON
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:14716 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-2700
Mailing Address - Country:US
Mailing Address - Phone:517-526-5368
Mailing Address - Fax:
Practice Address - Street 1:1116 TIMBERCREEK DR APT 29
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2306
Practice Address - Country:US
Practice Address - Phone:517-526-5368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86167503133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered