Provider Demographics
NPI:1750848701
Name:THORNTON-MALONE, WYNEISHIA
Entity Type:Individual
Prefix:
First Name:WYNEISHIA
Middle Name:
Last Name:THORNTON-MALONE
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 1:1460 E JOHN CV
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-6610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 E JOHN CV
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-6610
Practice Address - Country:US
Practice Address - Phone:662-580-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty