Provider Demographics
NPI:1881274546
Name:THORNBURGH, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THORNBURGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 LYNN CAMP RD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WV
Mailing Address - Zip Code:26421-8069
Mailing Address - Country:US
Mailing Address - Phone:304-659-3466
Mailing Address - Fax:
Practice Address - Street 1:5205 LYNN CAMP RD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WV
Practice Address - Zip Code:26421-8069
Practice Address - Country:US
Practice Address - Phone:304-659-3466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker