Provider Demographics
NPI:1679808943
Name:TALLEY, DANIELLE BEA (MA60106229)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:BEA
Last Name:TALLEY
Suffix:
Gender:F
Credentials:MA60106229
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5216
Mailing Address - Country:US
Mailing Address - Phone:360-876-4171
Mailing Address - Fax:360-876-3495
Practice Address - Street 1:200 BETHEL AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5216
Practice Address - Country:US
Practice Address - Phone:360-876-4171
Practice Address - Fax:360-876-3495
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60106229174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist