Provider Demographics
NPI:1679084628
Name:THACKER, ASHLEY LILLY (FNP-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LILLY
Last Name:THACKER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MICHAEL ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9534
Mailing Address - Country:US
Mailing Address - Phone:304-228-7291
Mailing Address - Fax:
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-766-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN71553-NP-C363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily