Provider Demographics
NPI:1861028193
Name:THOMAS, ANGELINA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:MARIE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2652 TWIN OAKS CT APT 52
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-5837
Mailing Address - Country:US
Mailing Address - Phone:314-323-6646
Mailing Address - Fax:
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:314-876-2585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020955367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered