Provider Demographics
NPI:1447797600
Name:THOMAS, KELDRECA SHUNTAE (FNP)
Entity Type:Individual
Prefix:
First Name:KELDRECA
Middle Name:SHUNTAE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W ALAMEDA ST STE 25
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1673
Mailing Address - Country:US
Mailing Address - Phone:505-988-8869
Mailing Address - Fax:
Practice Address - Street 1:1700 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2195
Practice Address - Country:US
Practice Address - Phone:478-464-8134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230389363LF0000X, 363LP0808X
NM55952363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily