Provider Demographics
NPI:1184221772
Name:THOMAS, CORETTA RENEE (LVN)
Entity Type:Individual
Prefix:
First Name:CORETTA
Middle Name:RENEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 G W JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-5604
Mailing Address - Country:US
Mailing Address - Phone:469-460-0882
Mailing Address - Fax:
Practice Address - Street 1:1204 G W JACKSON AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-5604
Practice Address - Country:US
Practice Address - Phone:469-460-0882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX303922164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse