Provider Demographics
NPI:1194575126
Name:THOMA, HEATHER (RN, QMHP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:THOMA
Suffix:
Gender:F
Credentials:RN, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95440 LILLIAN SLOUGH LN
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-7557
Mailing Address - Country:US
Mailing Address - Phone:330-819-8931
Mailing Address - Fax:
Practice Address - Street 1:137 HALL AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1519
Practice Address - Country:US
Practice Address - Phone:541-236-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHP-R-2651163WP0808X
OR201807240RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health