Provider Demographics
NPI:1306368162
Name:THORNTON, ANGEL CLARESE (STNA)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:CLARESE
Last Name:THORNTON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 HIGHLAND
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43610
Mailing Address - Country:US
Mailing Address - Phone:419-246-7014
Mailing Address - Fax:
Practice Address - Street 1:637 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43610-1144
Practice Address - Country:US
Practice Address - Phone:419-246-7014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHUG063459Medicaid