Provider Demographics
NPI:1619302791
Name:THACKER, GWENDOLYN IRENE (CNP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:IRENE
Last Name:THACKER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 MIAMISBURG CENTERVILLE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3674
Mailing Address - Country:US
Mailing Address - Phone:937-865-9000
Mailing Address - Fax:937-865-9002
Practice Address - Street 1:4000 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-7615
Practice Address - Country:US
Practice Address - Phone:937-865-9000
Practice Address - Fax:937-865-9002
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14947-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH258750Medicare PIN