Provider Demographics
NPI:1093596744
Name:INTAL, THEA DE GUZMAN (FNP-C)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:DE GUZMAN
Last Name:INTAL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:THEA
Other - Middle Name:
Other - Last Name:DE GUZMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:36 NEWARK AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-4122
Mailing Address - Country:US
Mailing Address - Phone:973-873-0195
Mailing Address - Fax:
Practice Address - Street 1:36 NEWARK AVE STE 300
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-4122
Practice Address - Country:US
Practice Address - Phone:973-873-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14933100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0960691Medicaid