Healthcare Provider Details

I. General information

NPI: 1487244711
Provider Name (Legal Business Name): TACKESHA TANESHA THOMAS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 S TACOMA WAY
LAKEWOOD WA
98499-4456
US

IV. Provider business mailing address

6811 S 204TH ST STE 280
KENT WA
98032-1352
US

V. Phone/Fax

Practice location:
  • Phone: 253-304-7753
  • Fax:
Mailing address:
  • Phone: 888-674-5871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number61136177
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61136177
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: