Healthcare Provider Details

I. General information

NPI: 1053652271
Provider Name (Legal Business Name): TALLEY S SOFIANOS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2013
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8832 US HIGHWAY 90
DAPHNE AL
36526-8932
US

IV. Provider business mailing address

14557 HIGHWAY 19 STE A
GRIFFIN GA
30224-9582
US

V. Phone/Fax

Practice location:
  • Phone: 251-289-1786
  • Fax:
Mailing address:
  • Phone: 678-688-1580
  • Fax: 678-688-1594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number006755
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: