Healthcare Provider Details

I. General information

NPI: 1467553313
Provider Name (Legal Business Name): NICOLE MONIQUE TAYLOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MANSFIELD AVE
WILLIMANTIC CT
06226-2018
US

IV. Provider business mailing address

40 MANSFIELD AVE
WILLIMANTIC CT
06226-2018
US

V. Phone/Fax

Practice location:
  • Phone: 860-450-7471
  • Fax: 860-450-0213
Mailing address:
  • Phone: 860-450-7471
  • Fax: 860-450-0213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number51756
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: