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General NPI Number Information
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NPI Number | 1114440534
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Entity Type | Individual
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Provider Name | ALEISHA NICOLE THEARLE PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/18/2017
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Last Update Date | 02/21/2025
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Provider Practice Location Address
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Address Line | 6821 PALISADES PARK CT STE 1
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City | FORT MYERS
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State | FL
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Zip | 33912-7131
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Country | US
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Telephone | 239-210-4660
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Fax |
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Provider Business Mailing Address
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Address Line | 5541 SPECTRA CIR APT 203
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City | FORT MYERS
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State | FL
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Zip | 33908-5384
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Country | US
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Telephone | 724-816-4839
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 9110478
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License Number State | FL
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