Provider Demographics
NPI:1205399508
Name:THACKER, MICHAEL DAVID (FNP-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:THACKER
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CLINCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3681
Mailing Address - Country:US
Mailing Address - Phone:423-247-7111
Mailing Address - Fax:
Practice Address - Street 1:100 CLINCHFIELD ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3681
Practice Address - Country:US
Practice Address - Phone:423-247-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000193250363LF0000X
VA00241777354363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily