Healthcare Provider Details

I. General information

NPI: 1003535287
Provider Name (Legal Business Name): MISS MALARY JEAN THORSBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 N HIGH ST
LANSING MI
48906-4597
US

IV. Provider business mailing address

1717 N HIGH ST
LANSING MI
48906-4597
US

V. Phone/Fax

Practice location:
  • Phone: 517-372-4700
  • Fax:
Mailing address:
  • Phone: 517-372-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1700901964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: