Provider Demographics
NPI:1043403843
Name:THURSTON, FANKIE (COTA)
Entity Type:Individual
Prefix:
First Name:FANKIE
Middle Name:
Last Name:THURSTON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 N KINGS HWY LOT 48
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1069
Mailing Address - Country:US
Mailing Address - Phone:903-831-3198
Mailing Address - Fax:
Practice Address - Street 1:5100 N KINGS HWY LOT 48
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1069
Practice Address - Country:US
Practice Address - Phone:903-831-3198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205027171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor