Provider Demographics
NPI:1710581673
Name:THOMAS, STEPHANIE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 FARR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2545
Mailing Address - Country:US
Mailing Address - Phone:678-779-2102
Mailing Address - Fax:
Practice Address - Street 1:4000 SHAKERAG HL STE 100
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4047
Practice Address - Country:US
Practice Address - Phone:770-954-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN201391163W00000X
GANCO-000001363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health