Provider Demographics
NPI:1548715923
Name:THEODORE, ARACELI
Entity type:Individual
Prefix:
First Name:ARACELI
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 BROADWAY PH 12
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2614
Mailing Address - Country:US
Mailing Address - Phone:347-294-3414
Mailing Address - Fax:205-332-1383
Practice Address - Street 1:632 BROADWAY PH 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2614
Practice Address - Country:US
Practice Address - Phone:347-294-3414
Practice Address - Fax:205-332-1383
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131527163WX1100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WX1100XNursing Service ProvidersRegistered NurseOphthalmic