Healthcare Provider Details

I. General information

NPI: 1417551169
Provider Name (Legal Business Name): SAMANTHA THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12495 LIMONITE AVE # 1095
EASTVALE CA
91752-2457
US

IV. Provider business mailing address

12495 LIMONITE AVE # 1095
EASTVALE CA
91752-2457
US

V. Phone/Fax

Practice location:
  • Phone: 909-328-6410
  • Fax: 909-265-9425
Mailing address:
  • Phone: 909-328-6410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95016064
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95016064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: