Provider Demographics
NPI:1558133389
Name:THORN, NELSON III (LPN)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:THORN
Suffix:III
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17891 BIRMINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4613
Mailing Address - Country:US
Mailing Address - Phone:313-859-1072
Mailing Address - Fax:
Practice Address - Street 1:2766 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3033
Practice Address - Country:US
Practice Address - Phone:248-542-2424
Practice Address - Fax:248-542-5621
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703126321164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse