Provider Demographics
NPI:1316567274
Name:WHITE-THOMASON, CHIQUITA
Entity type:Individual
Prefix:
First Name:CHIQUITA
Middle Name:
Last Name:WHITE-THOMASON
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 1:2500 MOUNT MORIAH RD APT 104
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-1523
Mailing Address - Country:US
Mailing Address - Phone:901-666-0810
Mailing Address - Fax:
Practice Address - Street 1:2500 MOUNT MORIAH RD STE H212
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-1523
Practice Address - Country:US
Practice Address - Phone:901-666-0810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN200001553172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN84-5020072Medicaid