Provider Demographics
NPI:1467281436
Name:THELISME, KATRINA JALIAH
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:JALIAH
Last Name:THELISME
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 MILLBURN AVE STE C7
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3747
Mailing Address - Country:US
Mailing Address - Phone:908-884-8419
Mailing Address - Fax:
Practice Address - Street 1:2130 MILLBURN AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3725
Practice Address - Country:US
Practice Address - Phone:973-843-7149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15230700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily