Provider Demographics
NPI:1942815238
Name:THORN, KATHLEEN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:THORN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ROSEHILL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1762
Mailing Address - Country:US
Mailing Address - Phone:517-488-4884
Mailing Address - Fax:517-212-2009
Practice Address - Street 1:770 KENMOOR AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8602
Practice Address - Country:US
Practice Address - Phone:616-272-3533
Practice Address - Fax:616-259-4839
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-13
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704294760363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily