Provider Demographics
NPI:1275558744
Name:THORN, ABIGAIL GRACE (ARNP CNM)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:GRACE
Last Name:THORN
Suffix:
Gender:F
Credentials:ARNP CNM
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 15399
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-5399
Mailing Address - Country:US
Mailing Address - Phone:850-765-8623
Mailing Address - Fax:850-765-0118
Practice Address - Street 1:1401 OVEN PARK DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-765-8623
Practice Address - Fax:850-765-0118
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2749192176B00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304656700Medicaid