Provider Demographics
NPI:1336576420
Name:THERRELL, THOMAS N (RN)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:N
Last Name:THERRELL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 501932
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92150-1932
Mailing Address - Country:US
Mailing Address - Phone:609-556-4005
Mailing Address - Fax:
Practice Address - Street 1:5525 GROSSMONT CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:92150
Practice Address - Country:US
Practice Address - Phone:609-556-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA672900163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse