Provider Demographics
NPI:1023386679
Name:THOMAS, MINNIE JO (CHA 3)
Entity Type:Individual
Prefix:
First Name:MINNIE
Middle Name:JO
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CHA 3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HILLSIDE ROAD
Mailing Address - Street 2:BOX 9
Mailing Address - City:BUCKLAND
Mailing Address - State:AK
Mailing Address - Zip Code:99727
Mailing Address - Country:US
Mailing Address - Phone:907-494-2122
Mailing Address - Fax:907-494-2104
Practice Address - Street 1:9 HILLSIDE ROAD
Practice Address - Street 2:BOX 9
Practice Address - City:BUCKLAND
Practice Address - State:AK
Practice Address - Zip Code:99727
Practice Address - Country:US
Practice Address - Phone:907-494-2122
Practice Address - Fax:907-494-2104
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11-1117-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker