Provider Demographics
NPI:1265930309
Name:PACE, TALISA
Entity type:Individual
Prefix:
First Name:TALISA
Middle Name:
Last Name:PACE
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 1:30 PARK PL APT 3020
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2750
Mailing Address - Country:US
Mailing Address - Phone:516-289-8716
Mailing Address - Fax:
Practice Address - Street 1:30 PARK PL APT 3020
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2750
Practice Address - Country:US
Practice Address - Phone:516-289-8716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist