Provider Demographics
NPI:1275057713
Name:THORN, MICHELLE DONELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DONELLE
Last Name:THORN
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 1:3245 LA COSTA CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7852
Mailing Address - Country:US
Mailing Address - Phone:707-425-6480
Mailing Address - Fax:
Practice Address - Street 1:2702 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-2789
Practice Address - Country:US
Practice Address - Phone:925-798-9240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program