Provider Demographics
NPI:1730626151
Name:THOMAS, KIANTE
Entity type:Individual
Prefix:
First Name:KIANTE
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11205 TIMBER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-5353
Mailing Address - Country:US
Mailing Address - Phone:903-363-7032
Mailing Address - Fax:
Practice Address - Street 1:2136 FM 757
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75705-4520
Practice Address - Country:US
Practice Address - Phone:903-590-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28007345172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker