=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366468175
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA L TALLMAN DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2006
-----------------------------------------------------
Last Update Date | 05/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2634 BRANDERMILL BLVD
-----------------------------------------------------
City | GAMBRILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-721-7201
-----------------------------------------------------
Fax | 410-721-7580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 NEW FIDELITY CT
-----------------------------------------------------
City | GARNER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27529-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-258-2714
-----------------------------------------------------
Fax | 410-648-4878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 20652
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------