Provider Demographics
NPI:1194349332
Name:THOM, KANESHA ALTHEA
Entity type:Individual
Prefix:
First Name:KANESHA
Middle Name:ALTHEA
Last Name:THOM
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 1:645 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-2904
Mailing Address - Country:US
Mailing Address - Phone:212-265-4500
Mailing Address - Fax:212-265-6565
Practice Address - Street 1:645 10TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-2904
Practice Address - Country:US
Practice Address - Phone:212-265-4500
Practice Address - Fax:212-265-6565
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307446164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse