Provider Demographics
NPI:1417767302
Name:THAYER, COURTNEY BRYCE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BRYCE
Last Name:THAYER
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 1:602 MIMOSA ST
Mailing Address - Street 2:
Mailing Address - City:BURKBURNETT
Mailing Address - State:TX
Mailing Address - Zip Code:76354-2350
Mailing Address - Country:US
Mailing Address - Phone:940-224-3610
Mailing Address - Fax:
Practice Address - Street 1:602 MIMOSA ST
Practice Address - Street 2:
Practice Address - City:BURKBURNETT
Practice Address - State:TX
Practice Address - Zip Code:76354-2350
Practice Address - Country:US
Practice Address - Phone:940-224-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1185946363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily