Provider Demographics
NPI:1255048351
Name:THOMAS, STACEY (CNA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 E 74TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-2312
Mailing Address - Country:US
Mailing Address - Phone:323-385-8298
Mailing Address - Fax:
Practice Address - Street 1:836 E 74TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-2312
Practice Address - Country:US
Practice Address - Phone:323-385-8298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA198603591310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility