Provider Demographics
NPI:1902316565
Name:REILLY, THERESA ANN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:REILLY
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 ROUTE 33
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753
Mailing Address - Country:US
Mailing Address - Phone:732-776-4292
Mailing Address - Fax:732-776-4213
Practice Address - Street 1:39 TORONTO DR
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-7531
Practice Address - Country:US
Practice Address - Phone:732-236-8361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431187363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care