Healthcare Provider Details

I. General information

NPI: 1083581490
Provider Name (Legal Business Name): THARA L GUILLORY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 STATION DR APT 1303
AVENEL NJ
07001-1869
US

IV. Provider business mailing address

1300 STATION DR APT 1303
AVENEL NJ
07001-1869
US

V. Phone/Fax

Practice location:
  • Phone: 386-868-9658
  • Fax:
Mailing address:
  • Phone: 386-868-9658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberN10571
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN9573108
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN9573108
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ15465900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: