Healthcare Provider Details

I. General information

NPI: 1053148338
Provider Name (Legal Business Name): AUDREY TALLIS DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CENTER ST
MOBILE AL
36604-3301
US

IV. Provider business mailing address

PO BOX 746450
ATLANTA GA
30374-6450
US

V. Phone/Fax

Practice location:
  • Phone: 251-415-1546
  • Fax: 251-415-1026
Mailing address:
  • Phone: 866-401-3057
  • Fax: 318-868-6430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number203315
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1-201155
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number203315
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: