Provider Demographics
NPI:1740892355
Name:THARALDSEN, ALLISON
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:THARALDSEN
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 1:1726 KINGSLEY AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4411
Mailing Address - Country:US
Mailing Address - Phone:904-291-5561
Mailing Address - Fax:
Practice Address - Street 1:1726 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4463
Practice Address - Country:US
Practice Address - Phone:904-291-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator