Provider Demographics
NPI:1982194411
Name:THOMAS, KATHRYN ANN (DOM)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4939 SE JACK AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6776
Mailing Address - Country:US
Mailing Address - Phone:772-634-0495
Mailing Address - Fax:
Practice Address - Street 1:4939 SE JACK AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6776
Practice Address - Country:US
Practice Address - Phone:772-634-0495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3919171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82-4961355OtherTIN