Healthcare Provider Details

I. General information

NPI: 1033048491
Provider Name (Legal Business Name): TAYLOR MARIE NICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1266 N FORWARD RD
LAKE CITY MI
49651-9393
US

IV. Provider business mailing address

1266 N FORWARD RD
LAKE CITY MI
49651-9393
US

V. Phone/Fax

Practice location:
  • Phone: 231-920-8152
  • Fax:
Mailing address:
  • Phone: 231-920-8152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAM570363712
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: