Healthcare Provider Details

I. General information

NPI: 1912245721
Provider Name (Legal Business Name): COREY CLINTON THOMAS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 WELLINGTON WAY SUITE 110
LEXINGTON KY
40513-1265
US

IV. Provider business mailing address

1055 WELLINGTON WAY SUITE 275
LEXINGTON KY
40513-1259
US

V. Phone/Fax

Practice location:
  • Phone: 859-219-2822
  • Fax: 859-219-2825
Mailing address:
  • Phone: 859-219-2828
  • Fax: 859-219-2840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3007604
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: