Provider Demographics
NPI:1376597518
Name:THORNTON, LEIA MARLENA (PAC)
Entity type:Individual
Prefix:
First Name:LEIA
Middle Name:MARLENA
Last Name:THORNTON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 GUNTER PARK DR EAST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109
Mailing Address - Country:US
Mailing Address - Phone:334-523-6395
Mailing Address - Fax:334-523-6390
Practice Address - Street 1:2650 GUNTER PARK DRIVE EAST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109
Practice Address - Country:US
Practice Address - Phone:334-523-6395
Practice Address - Fax:334-523-6390
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA435363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06437010Medicaid
AL009936221Medicaid
AL51533432OtherBCBS
FL1504297Medicaid
FL1504297Medicaid
AL051533432Medicare ID - Type Unspecified