Provider Demographics
NPI:1578169090
Name:THACKER, DEA (NP)
Entity Type:Individual
Prefix:
First Name:DEA
Middle Name:
Last Name:THACKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9206 HIGHWAY 11 W
Mailing Address - Street 2:
Mailing Address - City:MOORESBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37811-2318
Mailing Address - Country:US
Mailing Address - Phone:423-956-5485
Mailing Address - Fax:
Practice Address - Street 1:277 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2810
Practice Address - Country:US
Practice Address - Phone:865-262-9294
Practice Address - Fax:865-262-9295
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26209363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily