Provider Demographics
NPI:1821759515
Name:THURSTON, KATIE AUTUMN
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:AUTUMN
Last Name:THURSTON
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 1:4598 BROAD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-2839
Mailing Address - Country:US
Mailing Address - Phone:757-937-3558
Mailing Address - Fax:757-937-3979
Practice Address - Street 1:4598 BROAD ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2839
Practice Address - Country:US
Practice Address - Phone:757-937-3558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019018282225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist