Provider Demographics
NPI:1801288451
Name:THOMAS, AMBER NICOLE (ATC)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:NICOLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2140
Mailing Address - Country:US
Mailing Address - Phone:662-560-0602
Mailing Address - Fax:662-560-0603
Practice Address - Street 1:214 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2140
Practice Address - Country:US
Practice Address - Phone:662-560-0602
Practice Address - Fax:662-560-0603
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT07352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSAT0735OtherATHLETIC TRAINER