Provider Demographics
NPI:1609359165
Name:THOMAS, KENISHA VONCILLE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:KENISHA
Middle Name:VONCILLE
Last Name:THOMAS
Suffix:
Gender:
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 VETERANS MEMORIAL BLVD # 201
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-6321
Mailing Address - Country:US
Mailing Address - Phone:504-610-5194
Mailing Address - Fax:
Practice Address - Street 1:5825 MAGAZINE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-3218
Practice Address - Country:US
Practice Address - Phone:504-583-3230
Practice Address - Fax:763-402-7649
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV816281207Q00000X, 208D00000X, 363LP2300X, 363LX0106X, 363LF0000X
CA95009368207Q00000X, 208D00000X
CANP95009368363L00000X
LAAP215783363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609359165Medicaid