Healthcare Provider Details

I. General information

NPI: 1942115803
Provider Name (Legal Business Name): CECILIA MARIA TALLO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 WESTERN BLVD STE 122
JACKSONVILLE NC
28546-7637
US

IV. Provider business mailing address

461 WESTERN BLVD STE 122
JACKSONVILLE NC
28546-7637
US

V. Phone/Fax

Practice location:
  • Phone: 910-333-0283
  • Fax: 910-333-0513
Mailing address:
  • Phone: 910-333-0283
  • Fax: 910-333-0513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5025182
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: