Healthcare Provider Details

I. General information

NPI: 1104802511
Provider Name (Legal Business Name): DEBRA THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEBRA CHASE

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75438 CHIPPEWA LAKE RD.
BUTTERNUT WI
54514-9998
US

IV. Provider business mailing address

75438 CHIPPEWA LAKE RD.
BUTTERNUT WI
54514-9998
US

V. Phone/Fax

Practice location:
  • Phone: 715-769-3714
  • Fax:
Mailing address:
  • Phone: 715-769-3714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number27609
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: