Provider Demographics
NPI:1851069439
Name:TALLIS, NANCEYANNE
Entity Type:Individual
Prefix:
First Name:NANCEYANNE
Middle Name:
Last Name:TALLIS
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 1:947 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2939
Mailing Address - Country:US
Mailing Address - Phone:201-803-6559
Mailing Address - Fax:
Practice Address - Street 1:947 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2939
Practice Address - Country:US
Practice Address - Phone:201-803-6559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25NJ00649900363LA2200X
NJ26NJ00649900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health