Healthcare Provider Details

I. General information

NPI: 1407773476
Provider Name (Legal Business Name): AZMIRALDA THALJA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41-550 ECLECTIC PALM DESERT
PALM DESERT CA
92260
US

IV. Provider business mailing address

4804 GLADE ST
FORT WORTH TX
76114-1731
US

V. Phone/Fax

Practice location:
  • Phone: 877-205-6269
  • Fax:
Mailing address:
  • Phone: 817-718-7464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: