Provider Demographics
NPI:1053807586
Name:TALLEY, MARAYSHA TIERRA
Entity type:Individual
Prefix:
First Name:MARAYSHA
Middle Name:TIERRA
Last Name:TALLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MOOREWOOD ST APT 1022
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-2991
Mailing Address - Country:US
Mailing Address - Phone:731-609-5616
Mailing Address - Fax:
Practice Address - Street 1:301 W CALHOUN
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3508
Practice Address - Country:US
Practice Address - Phone:870-234-1597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities