Provider Demographics
NPI:1376016212
Name:THOMAS, TENNISHA L
Entity Type:Individual
Prefix:
First Name:TENNISHA
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 PEACE AVE NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-3255
Mailing Address - Country:US
Mailing Address - Phone:330-974-9586
Mailing Address - Fax:
Practice Address - Street 1:2171 PEACE AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-3255
Practice Address - Country:US
Practice Address - Phone:330-974-9586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0325265Medicaid