Provider Demographics
NPI:1215563440
Name:AUSTIN, TAYLOR NICOLE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:AUSTIN
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 1:6921 CAMBRIDGE
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49344-9600
Mailing Address - Country:US
Mailing Address - Phone:269-204-8246
Mailing Address - Fax:
Practice Address - Street 1:3101 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-5832
Practice Address - Country:US
Practice Address - Phone:269-204-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer