Provider Demographics
NPI:1477223105
Name:THOMAS, KEZIAH M (APRN)
Entity Type:Individual
Prefix:
First Name:KEZIAH
Middle Name:M
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 1:313 SUTHERLAND LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1937
Mailing Address - Country:US
Mailing Address - Phone:630-788-2435
Mailing Address - Fax:
Practice Address - Street 1:9325 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4271
Practice Address - Country:US
Practice Address - Phone:708-836-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily