=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174969588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. ANNETTE ANGELA THOMAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2013
-----------------------------------------------------
Last Update Date | 09/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18520 SATSUMA AVE
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33948-7520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-625-8264
-----------------------------------------------------
Fax | 941-625-8264
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18520 SATSUMA AVE
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33948-7520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-625-8264
-----------------------------------------------------
Fax | 941-625-8264
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6906610
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------