Provider Demographics
NPI:1407371750
Name:THOMAS, CHARISE
Entity type:Individual
Prefix:
First Name:CHARISE
Middle Name:
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 1:5056A MARDEL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1730
Mailing Address - Country:US
Mailing Address - Phone:314-262-1476
Mailing Address - Fax:
Practice Address - Street 1:5056A MARDEL AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1730
Practice Address - Country:US
Practice Address - Phone:314-262-1476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001549753251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO251E00000XMedicaid