Healthcare Provider Details

I. General information

NPI: 1164862769
Provider Name (Legal Business Name): KRISTIE APRIL TALLEY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 LAUREL BUSH RD
BEL AIR MD
21015-6191
US

IV. Provider business mailing address

2103 LAUREL BUSH RD
BEL AIR MD
21015-6191
US

V. Phone/Fax

Practice location:
  • Phone: 410-569-9533
  • Fax: 410-569-1254
Mailing address:
  • Phone: 410-569-9533
  • Fax: 410-569-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberR165331
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: