Healthcare Provider Details

I. General information

NPI: 1639568892
Provider Name (Legal Business Name): KATHERINE THAMES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15444 DEDEAUX RD SUITE B
GULFPORT MS
39503-2637
US

IV. Provider business mailing address

15444 DEDEAUX RD SUITE B
GULFPORT MS
39503-2637
US

V. Phone/Fax

Practice location:
  • Phone: 228-832-9038
  • Fax:
Mailing address:
  • Phone: 228-832-9038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR889394
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: