Provider Demographics
NPI:1073127999
Name:JOHNSON, TAYLOR NICOLE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:JOHNSON
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 1:9216 E PICKWICK CIR
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3813
Mailing Address - Country:US
Mailing Address - Phone:313-424-2664
Mailing Address - Fax:
Practice Address - Street 1:19853 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2066
Practice Address - Country:US
Practice Address - Phone:248-621-4792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJ525785630691390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI97296061Medicaid