Provider Demographics
NPI:1689375172
Name:THOMAS, SHAUNDRELE EVETTE
Entity Type:Individual
Prefix:
First Name:SHAUNDRELE
Middle Name:EVETTE
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 1:1151 HIGHWAY 51 N LOT 335
Mailing Address - Street 2:
Mailing Address - City:NESBIT
Mailing Address - State:MS
Mailing Address - Zip Code:38651-8446
Mailing Address - Country:US
Mailing Address - Phone:662-420-8814
Mailing Address - Fax:
Practice Address - Street 1:1151 HIGHWAY 51 N LOT 335
Practice Address - Street 2:
Practice Address - City:NESBIT
Practice Address - State:MS
Practice Address - Zip Code:38651-8446
Practice Address - Country:US
Practice Address - Phone:662-420-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10725246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty