Provider Demographics
NPI:1972813376
Name:PETERS, TALIA
Entity type:Individual
Prefix:MS
First Name:TALIA
Middle Name:
Last Name:PETERS
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 1:201 64TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220
Mailing Address - Country:US
Mailing Address - Phone:347-526-5079
Mailing Address - Fax:
Practice Address - Street 1:1809 NOSTRAND AVE.
Practice Address - Street 2:2ND FL. SUITE 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226
Practice Address - Country:US
Practice Address - Phone:718-421-4224
Practice Address - Fax:718-421-4774
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302375-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02386450Medicaid