Provider Demographics
NPI:1619176278
Name:TALLEY, ANGELA MICHELLE (LMT)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:MICHELLE
Last Name:TALLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MICHELLE
Other - Last Name:TALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:108 CALICO LOOP
Mailing Address - Street 2:
Mailing Address - City:GRANTVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30220-1766
Mailing Address - Country:US
Mailing Address - Phone:678-754-5762
Mailing Address - Fax:347-823-8404
Practice Address - Street 1:3025B HWY 154
Practice Address - Street 2:SUITE 108
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1166
Practice Address - Country:US
Practice Address - Phone:678-590-8040
Practice Address - Fax:347-823-8404
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT002072225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT002072OtherSTATE LICENSE