Provider Demographics
NPI:1295212926
Name:ROBERTSON, TALIAH MARIE
Entity type:Individual
Prefix:
First Name:TALIAH
Middle Name:MARIE
Last Name:ROBERTSON
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 1:727 GRANDVIEW MDWS DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-8932
Mailing Address - Country:US
Mailing Address - Phone:425-330-6366
Mailing Address - Fax:
Practice Address - Street 1:1455 DIXON AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8879
Practice Address - Country:US
Practice Address - Phone:425-330-6366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program