Provider Demographics
NPI:1417959917
Name:THOMAS, SUEANN (NP)
Entity Type:Individual
Prefix:
First Name:SUEANN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NP
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 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:
Practice Address - Street 1:3015 10TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-7090
Practice Address - Country:US
Practice Address - Phone:812-372-8426
Practice Address - Fax:812-378-7777
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001592A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000990887OtherANTHEM PIN
IN200511580Medicaid
IN1790837789OtherGROUP NPI NUMBER
IN144670OtherMEDICARE GROUP NUMBER
IN144670GMedicare PIN
IN200511580Medicaid
ININ2762048Medicare PIN