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General NPI Number Information
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NPI Number | 1558226910
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Entity Type | Individual
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Provider Name | ANTONIO TERELL THOMAS RN
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Gender | Male
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Dates
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Enumeration Date | 12/18/2025
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Last Update Date | 12/18/2025
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Provider Practice Location Address
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Address Line | 6805 STATE ROUTE 162
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City | MARYVILLE
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State | IL
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Zip | 62062-8530
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Country | US
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Telephone | 618-288-5019
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Fax |
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Provider Business Mailing Address
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Address Line | 117 TIMBERWOOD LN
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City | COLLINSVILLE
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State | IL
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Zip | 62234-6864
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Country | US
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Telephone | 314-324-0165
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 041563515
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License Number State | IL
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