Healthcare Provider Details

I. General information

NPI: 1790737963
Provider Name (Legal Business Name): THERESA SOUTAR R.N. APN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CHEWS LANDING RD
LAUREL SPRINGS NJ
08021-2769
US

IV. Provider business mailing address

402 LIPPINCOTT DR
MARLTON NJ
08053-4112
US

V. Phone/Fax

Practice location:
  • Phone: 856-227-6575
  • Fax: 856-374-9495
Mailing address:
  • Phone: 856-782-3300
  • Fax: 856-504-8029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26N009304400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: