Healthcare Provider Details

I. General information

NPI: 1194172981
Provider Name (Legal Business Name): MOYA TARA TALLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2016
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25140 AUSTIN DR
NEW BOSTON MI
48164-8907
US

IV. Provider business mailing address

25140 AUSTIN DR
NEW BOSTON MI
48164-8907
US

V. Phone/Fax

Practice location:
  • Phone: 313-461-5780
  • Fax:
Mailing address:
  • Phone: 313-461-5780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704327517
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: