Healthcare Provider Details

I. General information

NPI: 1700877412
Provider Name (Legal Business Name): JANE E KELLEY TALLMAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TAYLOR LN
RONCEVERTE WV
24970-1337
US

IV. Provider business mailing address

PO BOX 787
CRAB ORCHARD WV
25827-0787
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-3434
  • Fax: 304-647-9789
Mailing address:
  • Phone: 304-253-5793
  • Fax: 304-253-0166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1770
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1770
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: