Provider Demographics
NPI:1063583375
Name:MIDDLEBROOKS, TIESHAU (APN)
Entity type:Individual
Prefix:MRS
First Name:TIESHAU
Middle Name:
Last Name:MIDDLEBROOKS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S CHURCH ST STE 20
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2936
Mailing Address - Country:US
Mailing Address - Phone:609-239-1371
Mailing Address - Fax:
Practice Address - Street 1:1200 S CHURCH ST STE 20
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2936
Practice Address - Country:US
Practice Address - Phone:609-937-3491
Practice Address - Fax:609-853-0221
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ0089500363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health