Provider Demographics
NPI:1902539638
Name:TALLEY, DAVONTAE LYND SR
Entity Type:Individual
Prefix:
First Name:DAVONTAE
Middle Name:LYND
Last Name:TALLEY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 HOMEWOOD AVE SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-4226
Mailing Address - Country:US
Mailing Address - Phone:330-795-5023
Mailing Address - Fax:
Practice Address - Street 1:813 HOMEWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4226
Practice Address - Country:US
Practice Address - Phone:330-795-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-09
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health