Provider Demographics
NPI:1497245146
Name:THOMAS, STEPHENIE NICOLE
Entity Type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:NICOLE
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 1:900 BOARDMAN DR APT J96
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:GALLUP INDIAN MEDICAL CENTER
Practice Address - Street 2:516 E. NIZHONI BLVD
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267980163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Single Specialty