Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service | 20042882A | IN |
NPI | 1437442928 |
---|---|
Provider Name | Ms. Kelly Ann Thomas |
First Address | Bloomington, IN 47402-1329 |
Second Address | Bloomington, IN 47404-1187 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2011 |
Last Update Date | 06/08/2015 |