Provider Demographics
NPI:1386982411
Name:TALLEY, MARSHALL AVERY SR
Entity type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:AVERY
Last Name:TALLEY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MARSHALL
Other - Middle Name:AVERY
Other - Last Name:TALLEY
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1215 LAKEBLVD APT5
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302
Mailing Address - Country:US
Mailing Address - Phone:740-751-5655
Mailing Address - Fax:
Practice Address - Street 1:1215 LAKEBLVD APT5
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-751-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374061680794376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide