MEDICARE: DENITA KAYE THOMAS FNP

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	363LF0000X	Family Nurse Practitioner	R852967	MS

General Provider Information

NPI Number	:	1740479377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENITA KAYE THOMAS FNP

Provider Business Mailing Address
First Line	:	1122 E MAIN ST STE 6
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-2348
Country	:	US
Telephone Number	:	601-656-9900
Fax Number	:	601-656-9933

Provider Business Practice Location Address
First Line	:	1122 E MAIN ST STE 6
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-2348
Country	:	US
Telephone Number	:	601-656-9900
Fax Number	:	601-656-9933

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

Provider Enumeration Date	:	10/19/2007
Last Update Date	:	10/19/2007

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