Healthcare Provider Details

I. General information

NPI: 1417884057
Provider Name (Legal Business Name): TAYLOR GABRIELLE NICHOLS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 HAWTHORN ROW
VERNON HILLS IL
60061-1671
US

IV. Provider business mailing address

7396 N CENTRAL PARK
SHELBY TOWNSHIP MI
48317-2388
US

V. Phone/Fax

Practice location:
  • Phone: 586-292-5367
  • Fax:
Mailing address:
  • Phone: 586-292-5367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: