MEDICARE: MRS. LERETHA RENELL THOMAS R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	041219317	IL

General Provider Information

NPI Number	:	1073843231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LERETHA RENELL THOMAS R.N.

Provider Business Mailing Address
First Line	:	3912 WEST 76TH PLACE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-1316
Country	:	US
Telephone Number	:	773-884-0107
Fax Number	:	773-884-0553

Provider Business Practice Location Address
First Line	:	3912 W 76TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-1316
Country	:	US
Telephone Number	:	773-884-0107
Fax Number	:	773-884-0553

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2010
Last Update Date	:	01/11/2010

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