Provider Demographics
NPI:1497196018
Name:THACKER, KRISTEN A (MSED, LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:A
Last Name:THACKER
Suffix:
Gender:F
Credentials:MSED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MORRIS DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-3109
Mailing Address - Country:US
Mailing Address - Phone:910-547-0379
Mailing Address - Fax:
Practice Address - Street 1:111 MORRIS DR
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-3109
Practice Address - Country:US
Practice Address - Phone:910-547-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer