Provider Demographics
NPI:1306483631
Name:ASOLUKA, THECLA (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:THECLA
Middle Name:
Last Name:ASOLUKA
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 QUEENSBERRY RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-1561
Mailing Address - Country:US
Mailing Address - Phone:443-762-1210
Mailing Address - Fax:
Practice Address - Street 1:8258 VETERANS HWY STE 13
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1564
Practice Address - Country:US
Practice Address - Phone:410-768-6088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR143678363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD202061100Medicaid