Provider Demographics
NPI:1609359165
Name:THOMAS, KENISHA VONCILLE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:KENISHA
Middle Name:VONCILLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 N GREEN VALLEY PKWY # 469
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2120
Mailing Address - Country:US
Mailing Address - Phone:504-610-5194
Mailing Address - Fax:
Practice Address - Street 1:1485 W WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-7631
Practice Address - Country:US
Practice Address - Phone:702-482-9980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009368207Q00000X, 208D00000X
NV816281208D00000X, 363LF0000X
CANP95009368363L00000X
LAAP215783363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609359165Medicaid