Provider Demographics
NPI:1710569751
Name:THACKER, PENNY JANE
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:JANE
Last Name:THACKER
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 1:3152 CANAL PL
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-4503
Mailing Address - Country:US
Mailing Address - Phone:813-607-0079
Mailing Address - Fax:
Practice Address - Street 1:3152 CANAL PL
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-4503
Practice Address - Country:US
Practice Address - Phone:813-607-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide