Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | ME51658 | FL |
Y | 207NS0135X | Procedural Dermatology | ME51658 | FL |
NPI | 1508963315 |
---|---|
Provider Name | Pamela A Talley |
First Address | Saint Petersburg, FL 33713 |
Second Address | Saint Petersburg, FL 33713 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 23/11/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04579 | BLUE SHIELD (01) | |
D51057 | (02) |