Healthcare Provider Details

I. General information

NPI: 1326420100
Provider Name (Legal Business Name): ELIZABETH THOMAS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 W HIGH ST
BRYAN OH
43506-1681
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 419-636-4517
  • Fax: 419-636-6438
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704312691
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.17529
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: