Provider Demographics
NPI:1063243566
Name:THORNTON, DEAIRA
Entity type:Individual
Prefix:
First Name:DEAIRA
Middle Name:
Last Name:THORNTON
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 1:1855 FARNSLEY RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4701
Mailing Address - Country:US
Mailing Address - Phone:502-422-1150
Mailing Address - Fax:
Practice Address - Street 1:8521 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40242-3800
Practice Address - Country:US
Practice Address - Phone:502-426-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1179633163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health