MEDICARE: JEANIENE ANNE TALLEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	10389	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003889585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANIENE ANNE TALLEY MD

Provider Business Mailing Address
First Line	:	PO BOX 92001
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89193-2001
Country	:	US
Telephone Number	:	702-474-4110
Fax Number	:	702-240-8790

Provider Business Practice Location Address
First Line	:	3860 W ANN RD
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-4409
Country	:	US
Telephone Number	:	702-474-4110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	08/02/2021

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