Provider Demographics
NPI:1801877295
Name:THACH, JODENE R (CNP)
Entity type:Individual
Prefix:
First Name:JODENE
Middle Name:R
Last Name:THACH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7200 W 13TH ST N
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-2970
Mailing Address - Country:US
Mailing Address - Phone:316-217-6367
Mailing Address - Fax:316-295-2356
Practice Address - Street 1:7200 W 13TH ST N
Practice Address - Street 2:SUITE 5
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-2970
Practice Address - Country:US
Practice Address - Phone:316-239-7357
Practice Address - Fax:316-295-2356
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMCNP00557363LA2200X
KS36827363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML6477Medicaid
KS201091430AMedicaid
NM348526403Medicare ID - Type Unspecified
KSKA1655014Medicare PIN