Provider Demographics
NPI:1881146892
Name:KRIENKE, TALLY (CNM)
Entity type:Individual
Prefix:
First Name:TALLY
Middle Name:
Last Name:KRIENKE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:TALLY
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:700 N SAM HOUSTON PKWY W
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77067-4335
Mailing Address - Country:US
Mailing Address - Phone:832-828-1005
Mailing Address - Fax:
Practice Address - Street 1:700 N SAM HOUSTON PKWY W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77067-4335
Practice Address - Country:US
Practice Address - Phone:832-828-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCNM620367A00000X
TXAP138712367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1881146892Medicaid