Provider Demographics
NPI:1770042293
Name:TALLEY, NETITA
Entity Type:Individual
Prefix:
First Name:NETITA
Middle Name:
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 1:11835 QUEENS BLVD FL 6
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7211
Mailing Address - Country:US
Mailing Address - Phone:917-933-6927
Mailing Address - Fax:
Practice Address - Street 1:11835 QUEENS BLVD FL 6
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7211
Practice Address - Country:US
Practice Address - Phone:917-933-6927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker