Provider Demographics
NPI:1124633987
Name:THACKER, MISTY ROSE
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:ROSE
Last Name:THACKER
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:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:CRUM
Mailing Address - State:WV
Mailing Address - Zip Code:25669-0438
Mailing Address - Country:US
Mailing Address - Phone:304-393-3130
Mailing Address - Fax:
Practice Address - Street 1:230 WEBB ROAD
Practice Address - Street 2:
Practice Address - City:CRUM
Practice Address - State:WV
Practice Address - Zip Code:25669
Practice Address - Country:US
Practice Address - Phone:304-393-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant