Provider Demographics
NPI:1710395298
Name:THOMAS, KELLY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 E LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6304
Mailing Address - Country:US
Mailing Address - Phone:208-888-0909
Mailing Address - Fax:
Practice Address - Street 1:3520 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6304
Practice Address - Country:US
Practice Address - Phone:208-888-0909
Practice Address - Fax:208-888-5825
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1461A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily