Provider Demographics
NPI:1760905111
Name:TELLER, JAVON
Entity Type:Individual
Prefix:MS
First Name:JAVON
Middle Name:
Last Name:TELLER
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 1:1016 N OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401
Mailing Address - Country:US
Mailing Address - Phone:609-381-9877
Mailing Address - Fax:
Practice Address - Street 1:1016 N OHIO AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-2028
Practice Address - Country:US
Practice Address - Phone:609-381-9877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide