Provider Demographics
NPI:1073030110
Name:TAYLOR, NICHOLE DAWN (MS CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:DAWN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 S TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-2842
Mailing Address - Country:US
Mailing Address - Phone:309-525-0594
Mailing Address - Fax:
Practice Address - Street 1:1318 W 6TH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-1261
Practice Address - Country:US
Practice Address - Phone:309-852-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011743235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty