Healthcare Provider Details

I. General information

NPI: 1275746257
Provider Name (Legal Business Name): JEROME TALLEY CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 MONTREAT AVE SW
ATLANTA GA
30310-3322
US

IV. Provider business mailing address

1135 MONTREAT AVE SW
ATLANTA GA
30310-3322
US

V. Phone/Fax

Practice location:
  • Phone: 404-438-7530
  • Fax:
Mailing address:
  • Phone: 404-438-7530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number126167LGB
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: