Provider Demographics
NPI:1578522421
Name:TALLEY, WENDY G (MD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:G
Last Name:TALLEY
Suffix:
Gender:F
Credentials:MD
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 459
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-0459
Mailing Address - Country:US
Mailing Address - Phone:704-895-9060
Mailing Address - Fax:704-895-6494
Practice Address - Street 1:8311 MAGNOLIA ESTATES DR
Practice Address - Street 2:SUITE E
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8070
Practice Address - Country:US
Practice Address - Phone:704-895-9060
Practice Address - Fax:704-895-6494
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700406208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC791151UMedicaid
NC791151UMedicaid