Provider Demographics
NPI:1952340317
Name:THORN, ALLISON R (FNP)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:R
Last Name:THORN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 W. 4TH ST.,
Practice Address - Street 2:
Practice Address - City:GRANT CITY
Practice Address - State:MO
Practice Address - Zip Code:64456
Practice Address - Country:US
Practice Address - Phone:660-564-3322
Practice Address - Fax:660-564-3324
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005007476207Q00000X
MO2001017678363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1053452623OtherGRANT CITY CLINIC NPI
MO427378807Medicaid
MO505708305OtherGC CLINIC MEDICAID
IA0599373Medicaid
MOL280000OtherGC CLINIC GROUP MEDICARE
MO427378807Medicaid
IA0599373Medicaid