Provider Demographics
NPI:1508267931
Name:TALIAFERRO, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:TALIAFERRO
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 1:12475 DODGE RD
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9774
Mailing Address - Country:US
Mailing Address - Phone:810-919-9999
Mailing Address - Fax:
Practice Address - Street 1:12475 DODGE RD
Practice Address - Street 2:
Practice Address - City:OTISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48463-9774
Practice Address - Country:US
Practice Address - Phone:810-919-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704127352163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse