Provider Demographics
NPI:1205187333
Name:THOMAS, GWENDOLYNN NICOLE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYNN
Middle Name:NICOLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4201
Mailing Address - Country:US
Mailing Address - Phone:812-962-7890
Mailing Address - Fax:812-962-7117
Practice Address - Street 1:1107 CROWN POINTE DR STE 107
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7280
Practice Address - Country:US
Practice Address - Phone:270-506-3300
Practice Address - Fax:270-506-2843
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300009606Medicaid
9228980OtherAETNA PIN
CS1805200102OtherCARESOURCE ID
KY7100222860Medicaid
000001080865OtherANTHEM ID