Healthcare Provider Details

I. General information

NPI: 1174041230
Provider Name (Legal Business Name): LONNIE THOMAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 09/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8097 HIGH STREET
MONTEZUMA NY
13117
US

IV. Provider business mailing address

8097 HIGH ST
MONTEZUMA NY
13117-1715
US

V. Phone/Fax

Practice location:
  • Phone: 315-776-4935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number308442
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: