Basic Information
| Provider Information | |||||||||
| NPI: | 1013461425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | MARITESS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMAS-FORD | ||||||||
| OtherFirstName: | MARITESS | ||||||||
| OtherMiddleName: | GONZALES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1058 BEAR CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302281849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707070808 | ||||||||
| FaxNumber: | 7707071580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1058 BEAR CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302281849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707070808 | ||||||||
| FaxNumber: | 7707071580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2016 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN161969 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.