Provider Demographics
NPI:1962485110
Name:TALLEY, MARY ELIZABETH (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:TALLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:50 UNION ST
Mailing Address - Street 2:MAINE COAST MEMORIAL HOSPITAL
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1586
Mailing Address - Country:US
Mailing Address - Phone:207-664-5304
Mailing Address - Fax:207-664-5305
Practice Address - Street 1:50 UNION ST
Practice Address - Street 2:MAINE COAST MEMORIAL HOSPITAL
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1586
Practice Address - Country:US
Practice Address - Phone:207-664-5304
Practice Address - Fax:207-664-5305
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN037150367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000748371BMedicaid
MEMM216602Medicare PIN
MEMM2166Medicare PIN
GAHOSP35Medicare ID - Type UnspecifiedGROUP
GA000748371BMedicaid
MEMM216601Medicare PIN