Healthcare Provider Details

I. General information

NPI: 1285501429
Provider Name (Legal Business Name): TAYLOR MAKENZIE WATSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19291 NORTHLINE RD
SOUTHGATE MI
48195-2220
US

IV. Provider business mailing address

8393 MATHIAS DR APT 8
GROSSE ILE MI
48138-1748
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7726
  • Fax:
Mailing address:
  • Phone: 734-272-7994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704343485
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: