Provider Demographics
NPI:1073545042
Name:THORNTON, MARY (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:CFNP
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 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-249-2701
Mailing Address - Fax:601-249-2195
Practice Address - Street 1:300 RAWLS DR
Practice Address - Street 2:STE 1200
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2877
Practice Address - Country:US
Practice Address - Phone:601-249-4710
Practice Address - Fax:601-249-4716
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS533068363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118902Medicaid
MSS52332Medicare UPIN
MS00118902Medicaid