Provider Demographics
NPI:1871236984
Name:BALLA, THEJASWI
Entity Type:Individual
Prefix:
First Name:THEJASWI
Middle Name:
Last Name:BALLA
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 1:19 RICKARD CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2668
Mailing Address - Country:US
Mailing Address - Phone:978-677-0636
Mailing Address - Fax:
Practice Address - Street 1:19 RICKARD CT
Practice Address - Street 2:
Practice Address - City:LAWRENCE TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08648-2668
Practice Address - Country:US
Practice Address - Phone:978-677-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-16
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR22298100163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse