Provider Demographics
NPI:1679717847
Name:THOMAS, ROBERTA M (LPN)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 HOLT ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-6332
Mailing Address - Country:US
Mailing Address - Phone:937-938-6113
Mailing Address - Fax:
Practice Address - Street 1:242 HOLT ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-6332
Practice Address - Country:US
Practice Address - Phone:937-938-6113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN126257164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse