Provider Demographics
NPI:1861639015
Name:THOMAS, KATHERINE B (FNP, BC)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:B
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2089 SOUTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6478
Mailing Address - Country:US
Mailing Address - Phone:662-407-0801
Mailing Address - Fax:662-407-0807
Practice Address - Street 1:2089 SOUTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6478
Practice Address - Country:US
Practice Address - Phone:662-407-0801
Practice Address - Fax:662-328-3390
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR830346363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06436091Medicaid
MS512I500706Medicare PIN