Provider Demographics
NPI:1306168877
Name:THOMAS, EVONNE NA I (NURSE ASSISTANT)
Entity type:Individual
Prefix:MISS
First Name:EVONNE
Middle Name:NA
Last Name:THOMAS
Suffix:I
Gender:F
Credentials:NURSE ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 W PAULDING RD
Mailing Address - Street 2:412 WEST PAULDING ROAD
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-3430
Mailing Address - Country:US
Mailing Address - Phone:260-745-3619
Mailing Address - Fax:
Practice Address - Street 1:412 W PAULDING RD
Practice Address - Street 2:412 WEST PAULDING ROAD
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-3430
Practice Address - Country:US
Practice Address - Phone:260-745-3619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8902603047103K00000X
IN51202447103K00000X
IN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst