Provider Demographics
NPI:1629338967
Name:EXANTUS, THERESE
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:EXANTUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 S CENTER ST
Mailing Address - Street 2:APT C-1
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-3326
Mailing Address - Country:US
Mailing Address - Phone:973-609-0117
Mailing Address - Fax:
Practice Address - Street 1:324 S CENTER ST
Practice Address - Street 2:APT C-1
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-3326
Practice Address - Country:US
Practice Address - Phone:973-609-0117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307782164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse