Provider Demographics
NPI:1255564159
Name:THORNTON, ANGELA MARIE (CNM)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:THORNTON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:7641 LA SALLE BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206
Mailing Address - Country:US
Mailing Address - Phone:313-392-3010
Mailing Address - Fax:248-584-7606
Practice Address - Street 1:326 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-4121
Practice Address - Country:US
Practice Address - Phone:248-584-7600
Practice Address - Fax:248-584-7606
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704304402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA023123C08Medicare PIN
VA1255564159Medicaid