Provider Demographics
NPI:1194266759
Name:THITAVASANTA, MARIA (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:THITAVASANTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8536 101ST ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1111
Mailing Address - Country:US
Mailing Address - Phone:917-238-2548
Mailing Address - Fax:
Practice Address - Street 1:8536 101ST ST
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1111
Practice Address - Country:US
Practice Address - Phone:917-238-2548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327274251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJUP26529V01Medicaid