Provider Demographics
NPI:1336460070
Name:THACKER, VIBHA (MBA)
Entity Type:Individual
Prefix:MS
First Name:VIBHA
Middle Name:
Last Name:THACKER
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S RIVERSIDE DR
Mailing Address - Street 2:403
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-5500
Mailing Address - Country:US
Mailing Address - Phone:954-317-0082
Mailing Address - Fax:954-317-0083
Practice Address - Street 1:105 S RIVERSIDE DR
Practice Address - Street 2:403
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-5500
Practice Address - Country:US
Practice Address - Phone:954-317-0082
Practice Address - Fax:954-317-0083
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL231712372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion