Provider Demographics
NPI:1063970168
Name:THORNE, TINA MICHELLE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELLE
Last Name:THORNE
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 1:512 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4153
Mailing Address - Country:US
Mailing Address - Phone:208-250-7653
Mailing Address - Fax:
Practice Address - Street 1:512 5TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4153
Practice Address - Country:US
Practice Address - Phone:208-250-7653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60947363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health