Provider Demographics
NPI:1386450617
Name:THOMAS, SHANITA A
Entity type:Individual
Prefix:
First Name:SHANITA
Middle Name:A
Last Name:THOMAS
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 1:248 BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14206-2708
Mailing Address - Country:US
Mailing Address - Phone:716-574-4968
Mailing Address - Fax:
Practice Address - Street 1:248 BRISTOL ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14206-2708
Practice Address - Country:US
Practice Address - Phone:716-574-4968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334410164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse