Provider Demographics
NPI:1477024974
Name:THOMAS, TAWANNA (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2961 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-1049
Mailing Address - Country:US
Mailing Address - Phone:917-683-2243
Mailing Address - Fax:
Practice Address - Street 1:2961 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-1049
Practice Address - Country:US
Practice Address - Phone:917-683-2243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1744P3200X
1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management