Provider Demographics
NPI:1982077343
Name:THOMAS, DONNELL M
Entity Type:Individual
Prefix:
First Name:DONNELL
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
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 8060
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71148-8060
Mailing Address - Country:US
Mailing Address - Phone:318-286-0269
Mailing Address - Fax:
Practice Address - Street 1:1324 CAMILLE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108
Practice Address - Country:US
Practice Address - Phone:318-286-0269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-07
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator