Healthcare Provider Details

I. General information

NPI: 1164724134
Provider Name (Legal Business Name): DEBORAH V THOMAS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2010
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N BUCKEYE LANE
GOSHEN KY
40026-9708
US

IV. Provider business mailing address

1600 N BUCKEYE LANE
GOSHEN KY
40026-9708
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2453S
License Number StateKY

VIII. Authorized Official

Name: DEBORAH V THOMAS
Title or Position: PRESIDENT
Credential: ARNP
Phone: 502-897-0674