Provider Demographics
NPI:1780187377
Name:THOMAS, CARLA D
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:D
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:PO BOX 208733
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-8733
Mailing Address - Country:US
Mailing Address - Phone:312-203-8217
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5074
Practice Address - Country:US
Practice Address - Phone:917-715-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.017290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily