Provider Demographics
NPI:1386049187
Name:CLEGG, TALISA
Entity type:Individual
Prefix:
First Name:TALISA
Middle Name:
Last Name:CLEGG
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 1:712 FREBIS AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206
Mailing Address - Country:US
Mailing Address - Phone:614-843-4012
Mailing Address - Fax:
Practice Address - Street 1:712 FREBIS AVENUE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206
Practice Address - Country:US
Practice Address - Phone:614-843-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker