Provider Demographics
NPI:1851993836
Name:THOMAS, ELISE NICOLE (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:NICOLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8253 MOUNT CARMEL ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-6902
Mailing Address - Country:US
Mailing Address - Phone:937-520-1875
Mailing Address - Fax:
Practice Address - Street 1:8253 MOUNT CARMEL ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-6902
Practice Address - Country:US
Practice Address - Phone:937-520-1875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5718650Medicaid