MEDICARE: TD ADVANCED PRACTICE PROVIDER SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner

General Provider Information

NPI Number	:	1861273476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TD ADVANCED PRACTICE PROVIDER SERVICES, LLC

Provider Business Mailing Address
First Line	:	102 OKLAHOMA AVE
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19803-3236
Country	:	US
Telephone Number	:	856-340-8466
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 OKLAHOMA AVE
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19803-3236
Country	:	US
Telephone Number	:	856-340-8466
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TAMICA NICHOLE D'AGUIAR
Credential	:	NP
Telephone Number	:	856-340-8466

Provider Enumeration Date	:	10/10/2023
Last Update Date	:	10/10/2023

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