Provider Demographics
NPI:1871205880
Name:THELEMAQUE, NETHANIA
Entity type:Individual
Prefix:
First Name:NETHANIA
Middle Name:
Last Name:THELEMAQUE
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 1:6675 RAINWOOD COVE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7449
Mailing Address - Country:US
Mailing Address - Phone:561-932-7230
Mailing Address - Fax:
Practice Address - Street 1:11501 N MILITARY TRL
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6507
Practice Address - Country:US
Practice Address - Phone:561-805-2253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL62396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62396OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE