Provider Demographics
NPI:1083581490
Name:GUILLORY, THARA L
Entity type:Individual
Prefix:
First Name:THARA
Middle Name:L
Last Name:GUILLORY
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 1:1300 STATION DR APT 1303
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1869
Mailing Address - Country:US
Mailing Address - Phone:386-868-9658
Mailing Address - Fax:
Practice Address - Street 1:1300 STATION DR APT 1303
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1869
Practice Address - Country:US
Practice Address - Phone:386-868-9658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9573108163WR0006X, 363LA2200X
NYN10571363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant