Provider Demographics
NPI:1306591011
Name:THOMAS, SHIRLEY (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49288 GAVIOTA LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1164
Mailing Address - Country:US
Mailing Address - Phone:586-864-4703
Mailing Address - Fax:
Practice Address - Street 1:49288 GAVIOTA LN
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1164
Practice Address - Country:US
Practice Address - Phone:586-864-4703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704219948NSA2111G363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily