Provider Demographics
NPI:1376212605
Name:THORNTON, IDALIA (LPN)
Entity Type:Individual
Prefix:
First Name:IDALIA
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:LPN
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 23
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02838-0023
Mailing Address - Country:US
Mailing Address - Phone:601-209-5755
Mailing Address - Fax:
Practice Address - Street 1:230 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1408
Practice Address - Country:US
Practice Address - Phone:671-591-5400
Practice Address - Fax:671-591-5401
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN99461164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse