Provider Demographics
NPI:1891893376
Name:TALLEY, ANGELLA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELLA
Middle Name:MARIE
Last Name:TALLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-0038
Mailing Address - Country:US
Mailing Address - Phone:812-738-4251
Mailing Address - Fax:
Practice Address - Street 1:2201 CONCORD AVE NW
Practice Address - Street 2:STE 100
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2060
Practice Address - Country:US
Practice Address - Phone:812-738-1200
Practice Address - Fax:812-738-1710
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061972A174400000X
KY40534208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100206000Medicaid
IN200847430Medicaid
KYK040280Medicare PIN
KYK040281Medicare PIN