Healthcare Provider Details

I. General information

NPI: 1417688292
Provider Name (Legal Business Name): TALISA LAURAYNE TAIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 BLUERIDGE AVE STE 200
WHEATON MD
20902-4597
US

IV. Provider business mailing address

2401 BLUERIDGE AVE STE 200
WHEATON MD
20902-4597
US

V. Phone/Fax

Practice location:
  • Phone: 301-933-6440
  • Fax:
Mailing address:
  • Phone: 301-933-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0116036820
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: