Provider Demographics
NPI:1629495247
Name:THOMAS, MIRANDA DESHAWNA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:DESHAWNA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:4485 W STONE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-1050
Practice Address - Country:US
Practice Address - Phone:423-224-3150
Practice Address - Fax:423-224-3169
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024171552363LF0000X
TN21526363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I507786Medicare PIN