Basic Information
| Provider Information | |||||||||
| NPI: | 1366621344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TALLEY | ||||||||
| FirstName: | LOIS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MELTON | ||||||||
| OtherFirstName: | TALLEY | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL LN | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | DANVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461221989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177184730 | ||||||||
| FaxNumber: | 3177184733 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITAL LN | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | DANVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461221989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177184730 | ||||||||
| FaxNumber: | 3177184733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10000303A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.