Healthcare Provider Details

I. General information

NPI: 1871992966
Provider Name (Legal Business Name): TIFFANY DOMINIQUE THOMAS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 US HIGHWAY 41
SCHERERVILLE IN
46375-1311
US

IV. Provider business mailing address

PO BOX 916
HOMEWOOD IL
60430-0916
US

V. Phone/Fax

Practice location:
  • Phone: 219-765-6545
  • Fax: 219-227-8920
Mailing address:
  • Phone: 708-979-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209012017
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71005138A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: