Provider Demographics
NPI:1891384640
Name:THACKER, BRENDA KAY
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
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 1:3860 US HIGHWAY 62 NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-9070
Mailing Address - Country:US
Mailing Address - Phone:740-505-2279
Mailing Address - Fax:
Practice Address - Street 1:3860 US HIGHWAY 62 NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-9070
Practice Address - Country:US
Practice Address - Phone:740-505-2279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172A00000X, 3747P1801X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2819310Medicaid