Provider Demographics
NPI:1972179695
Name:THORMAN, DEIDRE JANELLE
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:JANELLE
Last Name:THORMAN
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 1:13011 146TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11436-2308
Mailing Address - Country:US
Mailing Address - Phone:347-248-8467
Mailing Address - Fax:
Practice Address - Street 1:13011 146TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11436-2308
Practice Address - Country:US
Practice Address - Phone:347-248-8467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty