Provider Demographics
NPI:1790283885
Name:THOMAS, JALISA BRIANNA (LPN)
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:BRIANNA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 FLETCHER STANLEY RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:GA
Mailing Address - Zip Code:31065-3310
Mailing Address - Country:US
Mailing Address - Phone:478-290-7248
Mailing Address - Fax:
Practice Address - Street 1:872 FLETCHER STANLEY RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:GA
Practice Address - Zip Code:31065-3310
Practice Address - Country:US
Practice Address - Phone:478-290-7248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN094885164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse