Provider Demographics
NPI:1861384216
Name:LALLER, TAILISH
Entity type:Individual
Prefix:
First Name:TAILISH
Middle Name:
Last Name:LALLER
Suffix:
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 1:7305 HENDERICKSON LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-2609
Mailing Address - Country:US
Mailing Address - Phone:317-225-0408
Mailing Address - Fax:
Practice Address - Street 1:7305 HENDERICKSON LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-2609
Practice Address - Country:US
Practice Address - Phone:317-225-0408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program