Healthcare Provider Details

I. General information

NPI: 1003738832
Provider Name (Legal Business Name): TIYANA THOMAS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N FREDERICK ST # 2201
CAPE GIRARDEAU MO
63701-9998
US

IV. Provider business mailing address

320 N FREDERICK ST # 2201
CAPE GIRARDEAU MO
63701-9998
US

V. Phone/Fax

Practice location:
  • Phone: 804-807-2278
  • Fax:
Mailing address:
  • Phone: 804-807-2278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number0001266463
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: