Provider Demographics
NPI:1376597518
Name:THORNTON, LEIA MARLENE (PAC)
Entity Type:Individual
Prefix:
First Name:LEIA
Middle Name:MARLENE
Last Name:THORNTON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4749 BERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106
Mailing Address - Country:US
Mailing Address - Phone:334-271-0280
Mailing Address - Fax:334-271-1918
Practice Address - Street 1:4749 BERRY BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106
Practice Address - Country:US
Practice Address - Phone:334-271-0280
Practice Address - Fax:334-271-1918
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06437010Medicaid
AL51533432OtherBCBS
FL1504297Medicaid
AL009936221Medicaid
FL1504297Medicaid
AL051533432Medicare ID - Type Unspecified