Provider Demographics
NPI:1881241123
Name:THOMAS, MARY ROSE (PMHNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:MS
Mailing Address - Zip Code:39359-0150
Mailing Address - Country:US
Mailing Address - Phone:601-625-7403
Mailing Address - Fax:601-625-7404
Practice Address - Street 1:1488 HWY 487
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:MS
Practice Address - Zip Code:39359
Practice Address - Country:US
Practice Address - Phone:601-625-7403
Practice Address - Fax:601-625-7404
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903412363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04387816Medicaid