Healthcare Provider Details

I. General information

NPI: 1366466492
Provider Name (Legal Business Name): GLYNNIS L THATCH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/27/2023
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13121 OLIO RD STE 300
FISHERS IN
46037
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-1300
  • Fax: 317-621-1310
Mailing address:
  • Phone: 317-621-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002292A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: