Healthcare Provider Details

I. General information

NPI: 1518071133
Provider Name (Legal Business Name): GRACE A TALLARICO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAIN ST
NASHUA NH
03064-2716
US

IV. Provider business mailing address

1 MAIN ST
NASHUA NH
03064-2716
US

V. Phone/Fax

Practice location:
  • Phone: 603-883-0005
  • Fax: 603-883-0007
Mailing address:
  • Phone: 603-883-0005
  • Fax: 603-883-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number10595
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: