Provider Demographics
NPI:1104413509
Name:THORNSBERRY, VICKI LEE
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LEE
Last Name:THORNSBERRY
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 1:21 MOHICAN TRL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1026
Mailing Address - Country:US
Mailing Address - Phone:567-231-9911
Mailing Address - Fax:
Practice Address - Street 1:21 MOHICAN TRL
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:44904-1026
Practice Address - Country:US
Practice Address - Phone:567-231-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X, 376J00000X
OH7003361385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child