Provider Demographics
NPI:1417798927
Name:TALLEY, MIA C
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:C
Last Name:TALLEY
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 1:800 WHITE PINE LN
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-4346
Mailing Address - Country:US
Mailing Address - Phone:240-858-9879
Mailing Address - Fax:
Practice Address - Street 1:12 MEDSTAR BLVD STE 325
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-1817
Practice Address - Country:US
Practice Address - Phone:410-877-8078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health