Provider Demographics
NPI:1194172981
Name:TALLEY, MOYA TARA (NP)
Entity type:Individual
Prefix:MRS
First Name:MOYA
Middle Name:TARA
Last Name:TALLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25140 AUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-8907
Mailing Address - Country:US
Mailing Address - Phone:313-461-5780
Mailing Address - Fax:
Practice Address - Street 1:25140 AUSTIN DR
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:MI
Practice Address - Zip Code:48164-8907
Practice Address - Country:US
Practice Address - Phone:313-461-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-21
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704327517363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily