Basic Information
Provider Information | |||||||||
NPI: | 1720419203 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TALLEY | ||||||||
FirstName: | LYNNE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN,FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708166038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2257655727 | ||||||||
FaxNumber: | 2257659196 | ||||||||
Practice Location | |||||||||
Address1: | 200 PROFESSIONAL DR | ||||||||
Address2: |   | ||||||||
City: | WEST MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712915359 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3189666535 | ||||||||
FaxNumber: | 3183227319 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2013 | ||||||||
LastUpdateDate: | 05/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP07585 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 045635 | 01 | LA | STATE NARCOTICS LICENSE | OTHER | 27-0345822 | 01 | LA | PGL TAX ID | OTHER | AP07585 | 01 | LA | STATE LICENSE | OTHER | MT3352008 | 01 | LA | DEA | OTHER |