Provider Demographics
NPI:1750894275
Name:JONATHAS, THAMARA VANESSA (APRN)
Entity type:Individual
Prefix:
First Name:THAMARA
Middle Name:VANESSA
Last Name:JONATHAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241-2170
Mailing Address - Country:US
Mailing Address - Phone:860-774-2020
Mailing Address - Fax:860-477-4708
Practice Address - Street 1:140 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1648
Practice Address - Country:US
Practice Address - Phone:860-456-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7176363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008085479Medicaid