Provider Demographics
NPI:1376040733
Name:TALLEY, TOWANDA LEE (LPN)
Entity Type:Individual
Prefix:
First Name:TOWANDA
Middle Name:LEE
Last Name:TALLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 CASPER AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45416-1517
Mailing Address - Country:US
Mailing Address - Phone:937-684-5270
Mailing Address - Fax:
Practice Address - Street 1:200 DARUMA PKWY
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-7909
Practice Address - Country:US
Practice Address - Phone:937-262-5919
Practice Address - Fax:937-496-5274
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162891.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse