Healthcare Provider Details

I. General information

NPI: 1609290717
Provider Name (Legal Business Name): DIANE THOMAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W
SAINT PAUL MN
55104-3727
US

IV. Provider business mailing address

1700 UNIVERSITY AVE W
SAINT PAUL MN
55104-3727
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-2202
  • Fax:
Mailing address:
  • Phone: 651-232-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0660
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number660
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: