Healthcare Provider Details

I. General information

NPI: 1891893376
Provider Name (Legal Business Name): ANGELLA MARIE TALLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 CONCORD AVE NW STE 100
CORYDON IN
47112-2060
US

IV. Provider business mailing address

PO BOX 38
CORYDON IN
47112-0038
US

V. Phone/Fax

Practice location:
  • Phone: 812-738-1200
  • Fax: 812-738-1710
Mailing address:
  • Phone: 812-738-4251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number01061972A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40534
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: