Provider Demographics
NPI:1518533637
Name:TAYLOR, NICKEA M
Entity Type:Individual
Prefix:
First Name:NICKEA
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 1:1464 MULBERRY LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-4032
Mailing Address - Country:US
Mailing Address - Phone:440-444-8349
Mailing Address - Fax:
Practice Address - Street 1:1464 MULBERRY LN
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-4032
Practice Address - Country:US
Practice Address - Phone:440-444-8349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-30
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH501115040506251E00000X, 372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0307236Medicaid
OHCS1928100128OtherCARE SOURCE