Provider Demographics
NPI:1447896725
Name:TATHAM, AMY L (PMHNP, BC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:TATHAM
Suffix:
Gender:F
Credentials:PMHNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PEBBLE LANE
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3502
Mailing Address - Country:US
Mailing Address - Phone:856-287-3847
Mailing Address - Fax:
Practice Address - Street 1:525 ROUTE 73 NORTH STE 104
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3008
Practice Address - Country:US
Practice Address - Phone:484-229-4545
Practice Address - Fax:630-882-0553
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC002993363LP0808X
NJ26NJ00969700363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty