Provider Demographics
NPI:1255721528
Name:THORNTON, RODNEESHA
Entity type:Individual
Prefix:
First Name:RODNEESHA
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NEESHA
Other - Middle Name:
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1209 HUNTER CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-7813
Mailing Address - Country:US
Mailing Address - Phone:916-821-5392
Mailing Address - Fax:
Practice Address - Street 1:500 LANIER AVE W STE 403
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7638
Practice Address - Country:US
Practice Address - Phone:916-821-5392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1218481744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management