Provider Demographics
NPI:1356528103
Name:JEANIENE A TALLEY MD A PROFESSIONAL
Entity type:Organization
Organization Name:JEANIENE A TALLEY MD A PROFESSIONAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEANIENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-474-4110
Mailing Address - Street 1:PO BOX 92001
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-2001
Mailing Address - Country:US
Mailing Address - Phone:702-218-0268
Mailing Address - Fax:
Practice Address - Street 1:3860 W ANN RD
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-4409
Practice Address - Country:US
Practice Address - Phone:702-474-4110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVH39014Medicare UPIN
NVV105306Medicare PIN