Healthcare Provider Details

I. General information

NPI: 1154862308
Provider Name (Legal Business Name): LAUREN SYMONE TALLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CHESTNUT ST # 5A
LOUISVILLE KY
40202-1713
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6879
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-7450
  • Fax: 502-588-7728
Mailing address:
  • Phone: 502-559-9407
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58014
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number58014
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: