Healthcare Provider Details

I. General information

NPI: 1871756189
Provider Name (Legal Business Name): MARYANN MOULDER THRASHER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 08/08/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 S. 240 W. SUITE 200 PROACTIVE MD. NEWTON COUNTY GOV/ SUITE 200
MORROCO IN
47963
US

IV. Provider business mailing address

100 LACY ST NW SUITE 150
MARIETTA GA
30060-1271
US

V. Phone/Fax

Practice location:
  • Phone: 219-209-4400
  • Fax: 833-525-2450
Mailing address:
  • Phone: 770-793-7635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP174775
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License NumberRN174775
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: