Provider Demographics
NPI:1780090308
Name:THAXTON, MARCIA (NP-C)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:THAXTON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22107 ANN ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2012 MONROE ST
Practice Address - Street 2:SUITE 207
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2938
Practice Address - Country:US
Practice Address - Phone:313-278-5836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269977363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily