Provider Demographics
NPI:1093347973
Name:OUTLAW-THOMAS, DONNA SHILANE (APRN-PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:SHILANE
Last Name:OUTLAW-THOMAS
Suffix:
Gender:F
Credentials:APRN-PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:SC
Mailing Address - Zip Code:29142-0405
Mailing Address - Country:US
Mailing Address - Phone:803-600-7106
Mailing Address - Fax:
Practice Address - Street 1:41 PARK CREEK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4270
Practice Address - Country:US
Practice Address - Phone:803-600-7106
Practice Address - Fax:803-610-4197
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC100313163WA2000X
SC363LP0808X363LP0808X
SC24101363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCL527Medicaid
SCSCL572Medicaid
SCRCO171Medicaid