Provider Demographics
NPI:1659883163
Name:TALLEY, MARVIENNE SHAWNTE
Entity Type:Individual
Prefix:
First Name:MARVIENNE
Middle Name:SHAWNTE
Last Name:TALLEY
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 1:686 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-2912
Mailing Address - Country:US
Mailing Address - Phone:216-235-2922
Mailing Address - Fax:
Practice Address - Street 1:686 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-2912
Practice Address - Country:US
Practice Address - Phone:216-235-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.359014163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health