Provider Demographics
NPI:1730836453
Name:THOMAS, TISHARAH ANTIONETTE
Entity type:Individual
Prefix:
First Name:TISHARAH
Middle Name:ANTIONETTE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4238 WILMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3139
Mailing Address - Country:US
Mailing Address - Phone:216-313-2035
Mailing Address - Fax:
Practice Address - Street 1:4238 WILMINGTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3139
Practice Address - Country:US
Practice Address - Phone:216-313-2035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRT000595Medicaid