Provider Demographics
NPI:1861261919
Name:THOMAS, TAEVONTE DAJOUN
Entity type:Individual
Prefix:
First Name:TAEVONTE
Middle Name:DAJOUN
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 1:1208 DORSEY LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-7076
Mailing Address - Country:US
Mailing Address - Phone:681-331-8533
Mailing Address - Fax:
Practice Address - Street 1:1208 DORSEY LN
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-7076
Practice Address - Country:US
Practice Address - Phone:681-331-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant