Provider Demographics
NPI:1710190624
Name:THIVENER, DAPHNE DAWN
Entity Type:Individual
Prefix:MRS
First Name:DAPHNE
Middle Name:DAWN
Last Name:THIVENER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 ELMONT PL
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9646
Mailing Address - Country:US
Mailing Address - Phone:614-679-6300
Mailing Address - Fax:
Practice Address - Street 1:4830 ELMONT PL
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9646
Practice Address - Country:US
Practice Address - Phone:614-679-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 095202164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2200371Medicaid