Individual
MRS. SANDRA FAYE THOMAS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
969 LAKELAND DR, JACKSON, MS 39216-4606
(601) 200-4714
(601) 200-5929
Mailing address
2500 N STATE STREET, JMM ROOM 2525, JACKSON, MS 39216-4500
(601) 984-6426
(601) 984-6439
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
R772161
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00125897
—
MS
01
—
00125907
MEDICAID INDIVIDUAL PTAN
MS
05
—
04587370
—
MS
01
—
1407870306
INDIVIDUAL NPI
MS
01
—
1659447878
GROUP NPI
MS
01
—
500001916
MEDICARE- GROUP NUMBER
MS
Enumeration date
07/26/2006
Last updated
11/30/2016
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