Provider Demographics
NPI:1821753377
Name:COLLINS, TALLEY (LPN)
Entity Type:Individual
Prefix:
First Name:TALLEY
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:GA
Mailing Address - Zip Code:30139-2937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:218 STONEWALL ST
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3628
Practice Address - Country:US
Practice Address - Phone:678-719-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN099777164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse