Basic Information
| Provider Information | |||||||||
| NPI: | 1184743882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | MARILYN | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3999 FORT CAMPBELL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422404929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708862205 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 506 HOPKINSVILLE ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423451104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703385211 | ||||||||
| FaxNumber: | 2703381624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 2851S | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.