Provider Demographics
NPI:1871232348
Name:THACKER, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
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 1:3716 LEFT FORK MILLERS FORK RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:WV
Mailing Address - Zip Code:25570-5344
Mailing Address - Country:US
Mailing Address - Phone:304-849-3113
Mailing Address - Fax:
Practice Address - Street 1:3716 LEFT FORK MILLERS FORK RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:WV
Practice Address - Zip Code:25570-5344
Practice Address - Country:US
Practice Address - Phone:304-849-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker