Healthcare Provider Details

I. General information

NPI: 1194595801
Provider Name (Legal Business Name): RAQUEL TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAQUEL HUMPHREY

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LIBERTY ST
BROCKTON MA
02301-5674
US

IV. Provider business mailing address

680 CENTRE ST
BROCKTON MA
02302-3308
US

V. Phone/Fax

Practice location:
  • Phone: 508-941-7100
  • Fax:
Mailing address:
  • Phone: 508-941-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2390456
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number353013
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: