Provider Demographics
NPI:1275746257
Name:TALLEY, JEROME (CNA)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:TALLEY
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 MONTREAT AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-3322
Mailing Address - Country:US
Mailing Address - Phone:404-438-7530
Mailing Address - Fax:
Practice Address - Street 1:1135 MONTREAT AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-3322
Practice Address - Country:US
Practice Address - Phone:404-438-7530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA126167LGB374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide