MEDICARE: EDNA THACKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1609542281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDNA THACKER

Provider Business Mailing Address
First Line	:	3733 LEFT FORK MILLERS FORK RD
Second Line	:
City	:	WAYNE
State	:	WV
Zip	:	25570-5345
Country	:	US
Telephone Number	:	304-849-5034
Fax Number	:

Provider Business Practice Location Address
First Line	:	3733 LEFT FORK MILLERS FORK RD
Second Line	:
City	:	WAYNE
State	:	WV
Zip	:	25570-5345
Country	:	US
Telephone Number	:	304-849-5034
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2021
Last Update Date	:	08/23/2021

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Directions to “ EDNA THACKER ” Practice Location

Language	Start Address	Practice Location

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