Healthcare Provider Details

I. General information

NPI: 1467966002
Provider Name (Legal Business Name): CONNIE SUE THOMAS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 BANCROFT WAY # MC4300
BERKELEY CA
94720-4301
US

IV. Provider business mailing address

2222 BANCROFT WAY # MC4300
BERKELEY CA
94720-4300
US

V. Phone/Fax

Practice location:
  • Phone: 510-642-6621
  • Fax:
Mailing address:
  • Phone: 510-642-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number285413
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: