Provider Demographics
NPI:1871258582
Name:THELEMAQUE, TAISHA
Entity Type:Individual
Prefix:
First Name:TAISHA
Middle Name:
Last Name:THELEMAQUE
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 1:9153 NUGENT TRL
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-6325
Mailing Address - Country:US
Mailing Address - Phone:561-319-4403
Mailing Address - Fax:
Practice Address - Street 1:9153 NUGENT TRL
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-6325
Practice Address - Country:US
Practice Address - Phone:561-319-4403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL139296367500000X
NY83295001367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered