1619176278 NPI number — MS. ANGELA MICHELLE TALLEY LMT

Table of content: MS. ANGELA MICHELLE TALLEY LMT (NPI 1619176278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619176278 NPI number — MS. ANGELA MICHELLE TALLEY LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TALLEY
Provider First Name:
ANGELA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TALLEY
Provider Other First Name:
ANGELA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619176278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 CALICO LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANTVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30220-1766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-754-5762
Provider Business Mailing Address Fax Number:
347-823-8404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3025B HWY 154
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-1166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-590-8040
Provider Business Practice Location Address Fax Number:
347-823-8404
Provider Enumeration Date:
07/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MT002072 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MT002072 . This is a "STATE LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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