Healthcare Provider Details

I. General information

NPI: 1487596599
Provider Name (Legal Business Name): LARA BETH THORNSBURY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 EVERGREEN CIR
POCA WV
25159-7540
US

IV. Provider business mailing address

804 EVERGREEN CIR
POCA WV
25159-7540
US

V. Phone/Fax

Practice location:
  • Phone: 304-437-7131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number111773
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: