Provider Demographics
NPI:1417517566
Name:FISCUS, TALEA
Entity Type:Individual
Prefix:
First Name:TALEA
Middle Name:
Last Name:FISCUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 556
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-0556
Mailing Address - Country:US
Mailing Address - Phone:907-715-2330
Mailing Address - Fax:
Practice Address - Street 1:609 S KNIK GOOSE BAY RD STE C
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8079
Practice Address - Country:US
Practice Address - Phone:907-357-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK114523225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist