Provider Demographics
NPI:1104356690
Name:THOMAS, KATHY DARLENE (REV)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:DARLENE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:REV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 N 35TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8845
Mailing Address - Country:US
Mailing Address - Phone:918-519-6721
Mailing Address - Fax:918-940-7411
Practice Address - Street 1:4408 N 35TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-8845
Practice Address - Country:US
Practice Address - Phone:918-519-6721
Practice Address - Fax:918-940-7411
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH082129486OtherDRIVERS LICENSE