Provider Demographics
NPI:1003889585
Name:TALLEY, JEANIENE ANNE (MD)
Entity type:Individual
Prefix:
First Name:JEANIENE
Middle Name:ANNE
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 92001
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-2001
Mailing Address - Country:US
Mailing Address - Phone:702-474-4110
Mailing Address - Fax:702-240-8790
Practice Address - Street 1:3860 W ANN RD
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-4409
Practice Address - Country:US
Practice Address - Phone:702-474-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3102827Medicaid
NV2018827Medicaid
NV2018827Medicaid
H39014Medicare UPIN