Provider Demographics
NPI:1497315071
Name:TALLIE, STELLA MARIE
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:MARIE
Last Name:TALLIE
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 1:1840 E CALVADA BLVD STE 9
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-5843
Mailing Address - Country:US
Mailing Address - Phone:951-707-6091
Mailing Address - Fax:
Practice Address - Street 1:1040 HALL AVE APT 1
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-3312
Practice Address - Country:US
Practice Address - Phone:951-707-6091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV372600000X, 372500000X, 376J00000X, 3747P1801X, 3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider