MEDICARE: TALISA LAURAYNE TAIT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	0116036820	VA

General Provider Information

NPI Number	:	1417688292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TALISA LAURAYNE TAIT

Provider Business Mailing Address
First Line	:	2401 BLUERIDGE AVE STE 200
Second Line	:
City	:	WHEATON
State	:	MD
Zip	:	20902-4597
Country	:	US
Telephone Number	:	301-933-6440
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 BLUERIDGE AVE STE 200
Second Line	:
City	:	WHEATON
State	:	MD
Zip	:	20902-4597
Country	:	US
Telephone Number	:	301-933-6440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2022
Last Update Date	:	06/11/2026

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Directions to “ TALISA LAURAYNE TAIT ” Practice Location

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