MEDICARE: MERCEDES L THOMAS CPNP, IBCLC

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	163WL0100X	Lactation Consultant (Registered Nurse)	R224496	MD
2	363LP0200X	Pediatric Nurse Practitioner	RN198323	GA
3	363LP0200X	Pediatric Nurse Practitioner	R224496	MD

General Provider Information

NPI Number	:	1366853186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERCEDES L THOMAS CPNP, IBCLC

Provider Business Mailing Address
First Line	:	2727 SKYVIEW DR UNIT 926
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-5010
Country	:	US
Telephone Number	:	404-635-6175
Fax Number	:

Provider Business Practice Location Address
First Line	:	12774 WISTERIA DR # 2841
Second Line	:
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-9998
Country	:	US
Telephone Number	:	404-635-6175
Fax Number	:

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

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	12/28/2020

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