Provider Demographics
NPI:1669817458
Name:COLE, TALLY S (FNP)
Entity Type:Individual
Prefix:
First Name:TALLY
Middle Name:S
Last Name:COLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TALLY
Other - Middle Name:S
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1805 WILLIAMSON CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8164
Mailing Address - Country:US
Mailing Address - Phone:615-331-5536
Mailing Address - Fax:615-331-3740
Practice Address - Street 1:1805 WILLIAMSON CT
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027
Practice Address - Country:US
Practice Address - Phone:615-331-5536
Practice Address - Fax:615-331-3740
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531988Medicaid