Healthcare Provider Details

I. General information

NPI: 1720402365
Provider Name (Legal Business Name): PHILIP TALLEY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 N GARFIELD ST SUITE 6
MIDLAND TX
79705-3415
US

IV. Provider business mailing address

4519 N GARFIELD ST SUITE 6
MIDLAND TX
79705-3415
US

V. Phone/Fax

Practice location:
  • Phone: 432-262-4528
  • Fax: 432-201-7274
Mailing address:
  • Phone: 432-262-4528
  • Fax: 432-201-7274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberCNP-02359
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP127457
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: