Healthcare Provider Details

I. General information

NPI: 1407870306
Provider Name (Legal Business Name): SANDRA FAYE THOMAS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

2500 N STATE STREET JMM ROOM 2525
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4714
  • Fax: 601-200-5929
Mailing address:
  • Phone: 601-984-6426
  • Fax: 601-984-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR772161
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: