Healthcare Provider Details

I. General information

NPI: 1043983786
Provider Name (Legal Business Name): DANIELLE THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/29/2026
Certification Date: 07/28/2021
Deactivation Date: 06/08/2025
Reactivation Date: 07/29/2026

III. Provider practice location address

1123 S WHITE STATION RD
MEMPHIS TN
38117-5831
US

IV. Provider business mailing address

1123 S WHITE STATION RD
MEMPHIS TN
38117-5831
US

V. Phone/Fax

Practice location:
  • Phone: 901-530-4107
  • Fax:
Mailing address:
  • Phone: 901-530-4107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number111052026
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: