Provider Demographics
NPI:1912327404
Name:THOMAS, TALLY
Entity Type:Individual
Prefix:
First Name:TALLY
Middle Name:
Last Name:THOMAS
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 1:2403 N CENTER ST #1
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-814-6923
Mailing Address - Fax:
Practice Address - Street 1:2403 N CENTER ST # 1
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-3594
Practice Address - Country:US
Practice Address - Phone:928-814-6923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0867171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist