Provider Demographics
NPI:1316683113
Name:WORRELL, AESHA
Entity type:Individual
Prefix:MISS
First Name:AESHA
Middle Name:
Last Name:WORRELL
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 1:100 S WOOD AVE APT 419
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-3364
Mailing Address - Country:US
Mailing Address - Phone:908-374-4653
Mailing Address - Fax:
Practice Address - Street 1:1250 HYLAN BLVD STE 9B1
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1945
Practice Address - Country:US
Practice Address - Phone:917-397-8947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist